Core Emergency Medicine
We review Sexually Transmitted Infections and pertinent updates in diagnosis and management.
Hosts:
Avir Mitra, MD
Brian Gilberti, MD
(1:49) Chlamydia
(3:31) Gonorrhea
(4:50) PID
(6:14) Syphilis
(8:08) Neurosyphilis
(9:13) Tertiary Syphilis
(10:06) Trichomoniasis
(11:13) Herpes
(12:49) HIV
(14:10) PEP
(15:13) Mycoplasma Genitalium
(18:00) Take Home Points
Chlamydia:
Gonorrhea:
Pelvic Inflammatory Disease (PID):
Syphilis:
Neurosyphilis:
Tertiary Syphilis:
Trichomoniasis:
Herpes Simplex Virus (HSV):
Human Immunodeficiency Virus (HIV):
Mycoplasma genitalium:
Key Take-Home Points:
We discuss migraines with one of the authorities in the field.
Hosts:
Benjamin Friedman, MD of Montefiore
Brian Gilberti, MD
Initial Approach to Diagnosing Migraines:
Effective Acute Migraine Treatments:
Treatments to Avoid or Use with Caution:
Managing Refractory Migraines:
Preventing Recurrence of Migraines:
Key Takeaways
We discuss a new class of medications, Immune Checkpoint Inhibitors, and their side effects.
Hosts:
Avir Mitra, MD
Brian Gilberti, MD
We discuss a case of ataxia in children and how to approach the evaluation of these pts.
Hosts:
Ellen Duncan, MD, PhD
Brian Gilberti, MD
Introduction
The Case
Differential Diagnosis
Importance of History and Physical Examination
Diagnostic Workup
Treatment Approach
Outcome of the Case Study
Take-Home Points
We discuss the approach to diagnosing and managing hypernatremia in the emergency department.
Hosts:
Abigail Olinde, MD
Brian Gilberti, MD
Episode Overview:
Definition and Pathophysiology:
Causes of Hypernatremia based on urine studies:
Risk Factors:
Diagnosis:
Management Strategies:
Monitoring and Follow-Up:
Take Home Points:
We discuss an approach to the acutely agitated patient and review medications commonly used.
Hosts:
Jonathan Kobles, MD
Brian Gilberti, MD
Background/Epidemiology
•Definition and Scope: Agitation encompasses behaviors from restlessness to severe altered mental states. It’s a common emergency department presentation, often linked with acute medical or psychiatric emergencies.
•Significance: Patients with agitation are at high risk for morbidity and mortality, necessitating prompt and effective management to prevent harm to themselves and healthcare providers.
A Changing Paradigm in Describing Agitation
•Terminology Shift: Move away from terms like ‘excited delirium’ due to their politicization and stigmatization. Focus on describing agitation by severity and underlying causes.
Agitation as a Multifactorial Process
•Complex Nature: Recognize agitation as a result of various factors, including medical, psychiatric, and environmental influences.
Recognizing Agitation
•Signs and Symptoms: Identify agitation early by monitoring for behaviors such as hostility, pacing, non-compliance, and verbal aggression.
Initial Evaluation
•Severity Assessment: Determine the severity of agitation and prioritize reversible causes and life-threatening conditions.
•Diagnostic Steps: Perform vital signs check, blood glucose levels, ECG, and a targeted medical screening exam.
Life Threats
•Immediate Concerns: Identify and address immediate life threats such as hypoxia, hypoglycemia, trauma, and acute neurological emergencies.
Forming a Differential Prior to Treatment
•Prioritization: Severe agitation requires immediate treatment to facilitate further evaluation and reduce risk of harm.
Physician/Staff Safety
•Safety Measures: Ensure personal and team safety by maintaining a calm environment and preparing for potential violence.
Multimodal Approach
•Self-check In: Physicians should mentally prepare and approach the situation calmly to ensure effective management.
•Verbal De-escalation: Use techniques focused on safety, therapeutic alliance, and patient autonomy to manage agitation non-pharmacologically.
Medication Administration
•Oral/Sublingual Medications: Consider oral medications for less severe cases to maintain patient autonomy and avoid invasive procedures.
•IM or IV Medications: Use intramuscular or intravenous medications for rapid control in severe cases.
Specific Medication Regimens
•PO Regimens:
•Medications: Antipsychotics like Zyprexa (olanzapine) 5-10 mg, benzodiazepines like Ativan (lorazepam) 1-2 mg.
•Benefits: Empower patients with a sense of autonomy, avoid injection-related trauma.
•Pharmacokinetics:
•Olanzapine: Onset in 15-45 minutes, peak effect in 1-2 hours, duration 12-24 hours.
•Lorazepam: Onset in 30-60 minutes, peak effect in 2 hours, duration 6-8 hours.
•IV/IM Regimens:
•Medications: Droperidol, haloperidol, midazolam, ketamine.
•ACEP 2023 Guidelines: Recommend droperidol with midazolam or an atypical antipsychotic for severe agitation.
•Pharmacokinetics (IM):
•Haloperidol: IM onset in 15, time to sedation ~25 minutes, can last for 2 hours
•Droperidol: IM onset in 5-10 minutes, duration 2-4 hours but can last as long as 12 hours
•Midazolam: IM onset ~15 minutes, , duration 20 minutes – 2 hours.
•Lorazepam: IM onset ~15-30 minutes, , duration up to 3 hours
•Ketamine: IM onset in ~5 minutes, duration 5-30 minutes.
Special Situations
•Elderly/Dementia: Optimize environment, use non-pharmacologic measures, avoid benzodiazepines to reduce delirium risk.
•Parkinson’s Disease: Avoid antipsychotics that can precipitate a Parkinsonian crisis.
•Autism/Pediatrics: Engage caregivers, create a calming environment, avoid aggressive measures.
•Alcohol Withdrawal: Utilize benzodiazepines and phenobarbital.
Re-dosing and Physical Restraints
•Re-dosing: Use the lowest effective dose, consider continuous monitoring, and reassess frequently.
•Physical Restraints: Employ as a last resort, ensuring close monitoring for any adverse effects.
Final Points
•Clinical Leadership: Physicians should lead with clear communication, planning, and support for the team.
•Continuous Learning: Regular debriefing and assessment after each incident to improve future responses.
We discuss an approach to the critically ill infant.
Hosts:
Ellen Duncan, MD, PhD
Brian Gilberti, MD
We review Acute Respiratory Distress Syndrome
Hosts:
Sadakat Chowdhury, MD
Brian Gilberti, MD
We review Nitrous Oxide Toxicity: Symptoms, diagnosis, and treatment overview
Hosts:
Stefanie Biondi, MD
Brian Gilberti, MD
Patient Case Illustration
Background and Recreational Use of Nitrous Oxide
Public Misconceptions and Health Consequences
Neurological Examination and Diagnosis
Physical Exam Findings: Upper vs Lower Motor Neuron Lesions
Localize the Lesion- Differential Diagnoses for Extremity Weakness
Localize the Lesion- Differential Diagnoses for Extremity Weakness
Localize the Lesion- Differential Diagnoses for Extremity Weakness
MRI Findings and Subacute Combined Degeneration
Pathophysiology of SCD due to Nitrous Oxide
Treatment and Management
Conclusion and Preventive Measures
References
We review threatened abortion and the complexities in its care.
Hosts:
Stacey Frisch, MD
Brian Gilberti, MD
Background
Initial Assessment and Management
Diagnostic Approach
Patient Counseling and Management
Follow-up and Precautions
Take Home Points
We review a general approach to syncope in children.
Hosts:
Brian Gilberti, MD
Ellen Duncan, MD
Take Home Points:
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