Episode 195: ARDS

We discuss an approach to the critically ill infant. Hosts: Ellen Duncan, MD, PhD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/The_Critically_Ill_Infant.mp3 Download Leave a Comment Tags: Pediatrics Show Notes The Critically Ill Infant: THE MISFITS Trauma ‘T’ in the mnemonic stands for trauma, which includes both accidental and intentional causes. Considerations for Non-accidental Trauma: Stresses the importance of considering non-accidental trauma, especially given that it may not always present with obvious external signs. Anatomical Vulnerabilities: Highlights specific anatomical considerations for infants who suffer from trauma: Infants have proportionally larger heads, increasing their susceptibility to high cervical spine (c-spine) injuries. Their liver and spleen are less protected, making abdominal injuries potentially more severe. Heart 5 T’s of Cyanotic Congenital Heart Disease: Introduces a mnemonic to help remember key right-sided ductal-dependent lesions: Truncus Arteriosus: Single vessel serving as both pulmonary and systemic outflow tract. Transposition of the Great Arteries: The pulmonary artery and aorta are switched, leading to improper circulation. Tricuspid Atresia: Absence of the tricuspid valve, leading to inadequate development of the right ventricle and pulmonary circulation issues.

We review Acute Respiratory Distress Syndrome Hosts: Sadakat Chowdhury, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/ARDS.mp3 Download Leave a Comment Tags: Critical Care, Pulmonary Show Notes Definition of ARDS: Non-cardiogenic pulmonary edema characterized by acute respiratory failure. Berlin criteria for diagnosis include acute onset within 7 days, bilateral pulmonary infiltrates on imaging, not fully explained by cardiac failure or fluid overload, and impaired oxygenation with PaO2/FiO2 ratio 5 cm H2O. Severity based on oxygenation (Berlin criteria): Mild: PaO2/FiO2 200-300 mmHg Moderate: PaO2/FiO2 100-200 mmHg Severe: PaO2/FiO2 Epidemiology: Occurs in up to 23% of mechanically ventilated patients. Mortality rate of 30-40%, primarily due to multiorgan failure. Differentiation from Cardiogenic Pulmonary Edema: Chest CT shows diffuse edema and pleural effusion in cardiogenic edema; patchy edema, dense consolidation in ARDS. Ultrasound may show diffuse B lines in cardiogenic edema; patchy B lines and normal A lines in ARDS. Pathophysiology: Exudative phase: Immune-mediated alveolar damage, pulmonary edema, cytokine release. Proliferative phase: Reabsorption of edema fluid. Fibrotic phase: Potential for prolonged ventilation. Etiology: Direct lung injury (pneumonia, toxins, aspiration, trauma, drowning) and indirect causes (sepsis, pancreatitis, transfusion reactions, certain drugs). Diagnostics: Comprehensive workup including imaging (chest X-ray, CT),

We review Nitrous Oxide Toxicity: Symptoms, diagnosis, and treatment overview Hosts: Stefanie Biondi, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Nitrous_Oxide_Toxicity.mp3 Download Leave a Comment Tags: Toxicology Show Notes Patient Case Illustration Hypothetical case: 21-year-old male with no previous medical history, experiencing a month of progressively worsening numbness, tingling, and weakness. Initially starting in his toes and spreading to his hips, and later involving his hands, the symptoms eventually escalated to the point of immobilization. Despite initially denying drug use, the patient admitted to using 40-60 canisters of nitrous oxide (whippets) every weekend for the last three months. Background and Recreational Use of Nitrous Oxide Nitrous oxide, a colorless, odorless gas with anesthetic properties. Synthesized in the 18th century. Its initial medical purpose expanded into recreational use due to its euphoric effects. Resurgence as a recreational drug during the COVID-19 lockdowns. Accessibility and legal status. Public Misconceptions and Health Consequences There are widespread misconceptions about nitrous oxide Particularly the belief in its safety and lack of long-term health risks. Contrary to popular belief, frequent use of nitrous oxide can lead to significant, sometimes irreversible, health issues. Neurological Examination and Diagnosis

We review threatened abortion and the complexities in its care. Hosts: Stacey Frisch, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Threatened_Abortion.mp3 Download One Comment Tags: OBGYN Show Notes Background Defined as vaginal bleeding during early pregnancy (before 20 weeks) with a closed cervical os, no passage of fetal tissue, and IUP on ultrasound Occurs in 20-25% of all pregnancies. Initial Assessment and Management Priority is to assess patient stability, establish good IV access, FAST may be helpful in identifying some ruptured ectopics early Broad differential diagnosis is crucial to avoid mistaking conditions like ectopic pregnancy for other emergencies. Importance of a detailed history and physical examination. Diagnostic Approach Essential tests include HCG level, urinalysis, and possibly CBC + blood type/Rh status. Rhogam’s use is well-supported in second and third trimester bleeding; however, data is less robust for first trimester bleeding in preventing sensitization Importance of interpreting b-HCG with caution and understanding HCG discriminatory zones. Use of ultrasound imaging, both bedside and formal, to assess the pregnancy’s status. Patient Counseling and Management Open and honest communication about the prognosis of threatened abortion. Addressing psychosocial aspects, including dispelling guilt and myths, and screening for intimate partner violence and mental hea...

We review a general approach to syncope in children. Hosts: Brian Gilberti, MD Ellen Duncan, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Syncope_in_Children.mp3 Download Leave a Comment Tags: Cardiology, Pediatrics Show Notes Initial Evaluation and Management: Similar initial workup for children and adults: checking glucose levels for hypoglycemia and conducting an EKG. The history and physical exam are crucial. Dextrose Administration in Children: Explanation of the ‘rule of 50s’ for determining the appropriate dextrose solution and dosage for children. ECG Analysis: Importance of ECG in diagnosing dysrhythmias like long QT syndrome, Brugada syndrome, catecholamine polymorphic V tach, ARVD, ALCAPA, and Wolff-Parkinson-White syndrome. Younger children’s dependency on heart rate for cardiac output and the risk of arrhythmias in kids with congenital heart disease. Condition Characteristic ECG Findings Congenital/Acquired Long QT Syndrome (LQTS) Prolonged QT interval Congenital/Acquired Wolff-Parkinson-White Syndrome (WPW) Short PR interval, Delta wave Congenital Brugada Syndrome ST elevation in V1-V3, Right bundle branch block Congenital Atrioventricular Block (AV Block) PR interval prolongation (1st degree), Missing QRS complexes (2nd & 3rd degree)

We go over the treatment of rapid atrial fibrillation (afib with RVR). Hosts: Brian Gilberti, MD Jonathan Kobles, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Rapid_Atrial_Fibrillation.mp3 Download One Comment Tags: Cardiology Show Notes Understanding AF with RVR Categories General AF with RVR: Definition and basic understanding. Rapid AF with Pre-excitation: Characteristics and complications. Chronic AF in Critical Illness: Identification and special considerations. Stability Assessment in AF with RVR ACLS Protocols: Distinction between unstable and stable patients. Unstable Patients: Immediate need for synchronized cardioversion, standard dose at 200 J for adults. Stable Patients: Rate vs. rhythm control strategies, consideration of underlying etiology. Limitations in Chronic AF: Challenges in patients with AF secondary to critical illness. ACLS Guidelines and ECG Findings Tachycardia with a Pulse Approach: Initial assessment guidelines. ECG Interpretation:

We discuss Electrical Storm (VT storm) and how to care for the very irritable heart. Hosts: Brian Gilberti, MD Reed Colling, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Electrical_Storm.mp3 Download Leave a Comment Tags: Cardiology Show Notes Background/Overview of VT: Definition: What makes it a storm  Three or more sustained episodes of VF, VT, or appropriate ICD shocks in a 24-hour period Pathophysiology: Understanding the origin and mechanism Sympathetic drive/adrenergic surge Underlying pathology: Sodium channelopathies, infiltrative disease like cardiac sarcoidosis, etc. RF’s / trigger / population (reversible cause in ~25% of patients) MI Electrolyte Derangements (emphasis on potassium and magnesium) New/worsening heart failure Catecholamine Surge Drugs (stimulants, cocaine, amphetamines, etc) QT Prolongation

We revisit the topic of Hyperkelamia to update our prior episode from 2015 (pre-Lokelma) Hosts: Brian Gilberti, MD Jonathan Kobles, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Hyperkalemia.mp3 Download 2 Comments Tags: Renal Colic Show Notes Introduction Background Physiology: Normal range and the significance of deviations (>5.5 mEq/L) Epidemiology: Prevalence of hyperkalemia in the ER ESRD missed HD → ECG, monitor Causes / Risk Factors Causes Kidney Dysfunction, Medications,  Cellular Destruction,  Endocrine Causes, Pseudohyperkalemia High-Risk Medications: Antibiotics: Bactrim, antifungals Calcineurin inhibitors Beta-blockers

We go over the essential and complex topic of vasopressors in the ED. Hosts: Brian Gilberti, MD Catherine Jamin, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Vasopressors.mp3 Download Leave a Comment Tags: Critical Care Show Notes Introduction Host: Brian Gilberti, MD Guest: Catherine Jamin, MD Associate professor of Emergency Medicine at NYU Langone Health Vice Chair of Operations Triple-boarded in Emergency Medicine, Internal Medicine, and Critical Care Medicine Topic: Vasopressors: Essential agents for supporting critically ill patients in the ED What Are Vasopressors and When to Use Them Two primary mechanisms to increase blood pressure: Increasing systemic vascular resistance via vasoconstriction Increasing cardiac output via augmenting inotropy and chronotropy Indicators for vasopressor use: MAP Signs of organ dysfunction like altered mental status, decreased urine output, elevated lactate Fluid resuscitation either ineffective or contraindicated (e.g., in CHF patients) Commonly Used Vasopressors in the ED Norepinephrine Epinephrine Vasopressin Phenylephrine Norepinephrine Mechanism: Stimulates alpha-1 (vasoconstriction) and beta-1 receptors (incre...

We discuss the diagnosis and management of septic arthritis in the pediatric population. Hosts: Brian Gilberti, MD Ellen Duncan, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Septic_Joint_in_Children.mp3 Download 2 Comments Tags: Infectious Diseases, Pediatrics Show Notes General Pain in joint for pediatric patient has a broad differential, including transient synovitis and septic arthritis Transient synovitis, also known as toxic synovitis, is a common condition affecting kids aged 3-10 and often occurs after a viral infection. It is typically self-limiting and not considered a serious condition. Septic arthritis is an infection in the joint space, typically affecting only one joint. It is often difficult to diagnose due to the fact that many patients, particularly under the age of 3, may not be able to localize their pain to a specific joint. Workup Diagnostic work-up for septic arthritis begins with blood work, which includes a complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and blood cultures. Lyme disease studies may also be necessary since Lyme disease can cause joint pain. Patients with transient synovitis typically have mild elevation in inflammatory markers,