Emguidewire's Podcast

The EMGuideWire Team is visited by a prior crew member, Russell Trigonis, MD! Join them as they discuss how the patient diagnosed with Sepsis in your ED has their care continued in the ICU! Pearls Start pressors with IVF (30-40cc/kg). NE at 7mcg/min peripherally can always be stopped, but better earlier than later. Increase NE until at 20mcg/min, if still hypotensive, then add a 2nd pressor like Vasopressin at 0.03units/min and 100mg Hydrocortisone Q8h. Start antibiotics early and identify source. CXR, US lungs/abd, UA, CT abd should all be considered.  Procalcitonin is helpful for stopping abx. Doesn’t change ED treatment. Don’t order Vitamin C or thiamine in ED. -Travis Barlock, MD

It it the end of Sepsis Awareness Month, but there is a BONUS Monday (Sept. 30th), so why not a BONUS episode! Join the EMGuideWire Team as they explore the challenges the children bring to this clinical condition. Let's review Pediatric Sepsis! Pearls: Screening should be age adjusted. Identify severe sepsis. Treat w/early antibiotics, balanced fluid administration, and EPI if needed.   SIRS in children must be age-adjusted. HR & RR > 2 standard deviations of nml; WBC age adjusted.  Screen: high risk medical history + vital sign abnormalities (age based SIRS) require check of cap refill, mental status, and general appearance followed by a physician assessment. Identify: Severe sepsis = sepsis + organ dysfunction (CV/resp/neuro/renal/hepatic dysfunction). Order a lactate, CBC, CMP, and blood cultures, and consider CXR and UA. CRP is helpful for inpatient team.  Higher lactate has higher mortality and is associated with septic shock. Treat: Start 20cc/kg bolus LR and reassess. Those with heart disease can

Join the EMGuideWire Crew as they continue to explore the High Yield management points for Sepsis!  This week's Episode's Pearls: Early fluids save lives. Give 40cc/kg bolus in first 3 hours. But don’t fluid overload the patient! U/S the heart and lungs: A plethoric IVC, immobile mitral valve, and B lines on the lungs should urge you to be more cautious with fluids. Goal in all patients is to establish an adequate MAP ASAP! Fluids + Vasopressors! Vasopressor titration algorithm: First low dose NE (10mcg/min); if still in shock, initiate vasopressin (0.04 units/min); do not wait on providing vasopressin if EPI is readily available (establish MAP ASAP!).  Initiate vasopressors early with fluids! NE can be initiated peripherally, so don’t wait for a central line! Only consider dopamine for absolute bradycardia.  Methylene blue is a last resort consideration.  Vasopressors are commonly needed at high doses (i.e., 1mcg/kg/min EPI).  Hydrocortisone 50-100mg for patients with septic SHOCK, not seps

Join the EMGuideWire crew once again for this month's series on Sepsis in honor of Sepsis Awareness month. Episode 3 will cover antibiotic use and selection. Antibiotics for Sepsis Take a history and perform a chart biopsy first! Consider past infections, bug susceptibilities, healthcare acquired vs. community acquired infection, foreign travel, and comorbidities.  Always check local antibiogram and prior culture results. Septic shock - Start broad spectrum antibiotics within 1 hour. Stable patient - find the source! UA, CXR, and a good skin exam are fast and can help guide antibiotic choice. Remember some patients need surgical management!  Antibiotic choice in septic shock. 1st agent - Piperacillin/Tazobactam (covers GP/GN + Pseudo)  2nd agent - Choose based on patient characteristics Ceftriaxone - simple community acquired infections. Vancomycin - covers MRSA. Meropenem - use for patients with a hx of ESBL. Flagyl + cefepime/meropenem - Use for intra-abdominal infections. Clindamycin - Useful for skin

Sepsis Awareness Month continues! Join the EMGuideWire Team as they dive into the issues of Fluid selection for resuscitation.  1) Fluids are not all created equal. Use balanced fluids for large volume resuscitation. 2) Lactated Ringers is likely the best choice available in the ED. Plasmalyte is also a good option, if you have it. 3) You can start low dose vasopressors peripherally if you need to, rather than continuing to flood patients with fluids for hypotension.

Join the EMGuideWire Team,from Carolinas Emergency Medicine Residency Program in Charlotte, NC, as they explore the critical core concepts on the important topic of Sepsis. In this first episode, the team will discuss the definitions of Sepsis. Pearls: Sepsis is a dysregulated systemic inflammatory response to infection causing intravascular inflammation, tissue ischemia, cytopathic injury, and dysregulated apoptosis. SIRS terminology is now outdated. Current terminology is “Sepsis” (SIRS, suspected source, end organ damage) and “Septic Shock.” Septic shock: SBP 22, AMS, SBP < 100; 2-3 points = poor outcomes. Epidemiology: 164,000 cases annually. Bacterial etiology most common. Mortality for sepsis and septic shock is 10 and 40% respectively. Summarized by Travis Barlock, MD PGY-1 References: Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. New England Journal of Medicine 2003; 348:1546. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Cl

Join the EMGuideWire Team, from Carolinas Emergency Medicine Residency Program in Charlotte, NC, as they explore the critical core concepts on the important topic of Sepsis. Over the course of September, Sepsis Awareness Month, the group will cover a variety of high-yield points to help make us all better at recognizing, evaluating, and managing Sepsis. This is the Intro to the month. Follow us every week for more information... and maybe even get a Bonus 5th episode as a reward!

Join the EMGuideWire team from Carolinas Medical Center Emergency Medicine Residency Program as they discuss the challenging condition of thyrotoxicosis and thyroid storm! From evaluation to management, this critical state requires our respect and attention!

Join the EMGuideWire crew as they explore the various skin and soft tissue infections that are commonly encountered and considered in the Emergency Department. While some may be minor, like furuncles, others can be life-threatening, like necrotizing fasciitis. 

Join the EMGuideWire Team as they explore the Basic Principles that must be considered when managing a pediatric airway. Knowledge of the anatomic and physiologic differences that exist between adults and children is paramount! Assuming that all pediatric airways are going to be "difficult" may help keep us prepared.

Join the EMGuideWire Team as they discuss some of the tips for having a successful and safe Sign-Out in the ED. Hear from recent graduates from the Carolinas Medical Center Emergency Medicine Program as they discuss their perspectives on Transition of Care in the ED.

Join the EMGuideWire Team as they are joined by two Pediatric EM experts (Drs. Simone Lawson and Pat Morgan) to discuss the very important and challenging topic of Pediatric Non-Accidental Trauma (NAT). Let's discover ways to remain help pick up on the subtle and sentinel cases to help protect our most vulnerable patients.

Join Dr. Driscoll from the EMGuideWire crew as he enters the Sports Medicine Corner once again. Today, he covers some of the issues with athlete cardiac screening and sudden cardiac death in athletes.

Join the EMGuideWire Team as they discuss the evaluation and management of Myasthenia Gravis and a Myasthenic Crisis! Learn about the means to assess a patient's ability to maintain her/his own airway.

Join the EMGuidewire team from CMC EM program as they discuss a potentially critical condition, HyperKalemia. Review the important HyperKalemia EKG Changes and be ready to take action!

Join the Ped EM Fellows from Carolinas Medical Center and the EMGuideWire as they discuss the seemingly simple issue of Pediatric Urinary Tract Infections. Who needs to be test and how do we do so? Let's review this less than simple topic.

Join Drs. Trigonis and Murray from the EMGuideWire team as they discuss use and selection of Vasopressors in the ED. 

Join the EMGuideWire Team, from the CMC EM program, as they enter the TOXIDome once again to wrestle with Aspirin (ASA) Toxicity! 

The patient is agitated and combative and a danger to everyone in the ED. What do you give? Haloperidol and lorazepam?  Maybe there are better choices. Join the EMGuideWire crew as they enter the TOXIDome to discuss a better approach to the management of the Agitated Patient.

Join the EMGuideWire team as they enter the TOXIDome once again and review Toxidromes with Dr. Kopec!