Join the EMGuideWire Team from CMC EM group as they explore the initial thoughts and management of a patient who presents with severe Diabetic Ketoacidosis (DKA). For this episode, Drs. Claire Milam and Travis Barlock explore the initial considerations and practical management tips. Definitions of severity of DKA: Mild pH: 7.25-7.3 CO2: 15-18 mEq/L Anion Gap: > 10 mEq/L Mental Status: Alert Blood Glucose: >250 mg/dl Urine and Serum Ketones: Positive   Moderate pH: 7.0-7.24 CO2: 10-15 mEq/L Anion Gap: >12 mEq/L Mental Status: Alert to Drowsy Blood Glucose: >250 mg/dl Urine and Serum Ketones: Positive   Severe pH: < 7.0 CO2: < 10 mEq/L Anion Gap: > 12 mEq/L Mental Status: Stuporous to Comatose Blood Glucose: >250 mg/dl Urine and Serum Ketones: Positive 

EMGuidewire's Podcast

Diabetic Ketoacidosis Emergent Management

Join the Drs. Ray and Barlock from the EMGuideWire team as the discuss the initial assessment and evaluation of some ocular complaints with specific attention to pathology of the Posterior Eye. SHOWNOTES: Key PointsAlways get visual acuity for any eye complaint Swinging flashlight test can help with your diagnosis Dilate the eyes for optimal fundoscopic exam Optic neuritis -> give IV steroids Use U/S to look for papilledema along with optic nerve sheath diameter Find the optic nerve when evaluating retinal detachment vs vitreous hemorrhage CRAO= “stroke of the eye” CRVO= “DVT of the eye” Optic NeuritisOnset: Acute Pain: With EOMI, can be painless Visual Acuity: Decreased Laterality: Usually unilateral, can be bilateral Classic presentation: Young female (15-45) with acute vision loss Exam: + APD Associations: MS, infection (lyme, herpes, syphilis), autoimmune, methanol, DM Treatment: IV steroids Papilledema Onset: Subacute to chronic Pain: Headache Visual Acuity: Normal initially Laterality: Bilateral Classic presentation: Headache, N/V, transient vision loss Exam: Optic disc swelling Treatment: treat underlying cause Retinal Detachment Onset: Sudden Pain: No Visual Acuity: Impaired Laterality: Unilateral Classic presentation: Sudden, painless, with flashes, or a curtain over the visual field Exam: +/- mild APD Management: Ophtho consult, minimize activity, treat underlying cause, surgical options available Central Retinal Artery OcclusionOnset: Sudden Pain: No Visual Acuity: Impaired Laterality: Unilateral Classic presentation: Sudden, painless vision loss in vasculopathy Exam: + APD Associations: carotid vascular disease, pediatric blood disorders (SCD, leukemia) Management: Ophtho consult, restore blood flow Central Retinal Vein OcclusionOnset: Acute Pain: No Visual Acuity: Impaired Laterality: Unilateral Classic presentation: Sudden blurry or distorted vision in hypercoagulable patient Exam: + APD Associations: OCPs, HTN, DM, vasculitis Management: Ophtho consult

Posterior Eye Pathology Core Concepts

Join the EMGuidewire team as Drs. Serven and Blackwell discuss the management of the patient presenting with Severe Status Asthmaticus in the Emergency Department. Don't forget to review the basic concepts that were published earlier... this time the focus is on the critically ill patient.

Severe Asthma Management in the ED

Join the EMGuidewire Team as they address how to prepare for the arrival of a trauma patient in your Emergency Department. Drs. Serven and Blackwell from Carolinas Medical Center Emergency Medicine Residency Program will give us some insight and pearls on how to manage the potential chaos. 

Trauma Assessment

Join Drs. Serven and Blackwell from the EMGuidewire team (from the Carolinas Medical Center Emergency Medicine Residency) as they discuss some of the Basic strategies to the initial evaluation and management of a patient with significant Bradycardia. See website (www.emguidewire.com) for complete show notes... but here is a sneak peak: Quick Differential: DIMES D – drugs (digoxin, CCB, beta blockers, cholinergic drugs, TCAs, Clonidine) I – ischemia (heart and brain)/ infection (sepsis, Lyme disease) M – metabolic (hypothyroid, hypoglycemia, hypothermia) E – electrolytes (hyperkalemia, hypokalemia, hypercalcemia, hypocalcemia, hypermagnesemia) S – sinus dysfunction (SSS, AV block) 

Approach to Bradycardia in the Emergency Department

Join the EMGuideWire team as Drs. Serven and Shreve are joined by Dr. Trigonis to discuss simple strategies to make sure your room is set up and you are prepared for performing an emergent intubation on your patients in the Emergency Department. Shownotes - Once through start to finish:  Set up suction  Set up pre-oxygenation (nasal cannula, NRB, BVM as backup) Choose a tube + back up tube  Lube the tube, check the tube  Choose a stylet Set up video and DL  Ask nurse for meds (nicely)  Check hemodynamics  Acknowledge preoxygenation  Positioning  Give meds  Wait for paralytic medications to work Tube ‘em   Call out your tube positioning  Leave the blade in place until tube placement assured  Confirm with color change, EtO2, bilateral breath sounds  Wait for RT to secure the tube Call for post-intubation meds  Check CXR for position  

Airway Management Preparation

Join Drs. Alyssa Thomas and Victoria Serven from Carolinas Medical Center Emergency Medicine Residency Program and the EMGuideWire Team as they discuss how they initially evaluate and manage the patient who present with acute pulmonary edema and hypertension. 

Pulmonary Edema and Hypertension

Join the EMGuideWire team as they explore the use of Point-of-Care Ultrasound for the evaluation of patients with possible COVID-19 infection. Dr. Patrick Lam, from the Carolinas Medical Center Department of Emergency Medicine Department Division of Ultrasound, will guide us on the techniques and pro-tips for this application.

Point of Care Ultrasound for COVID-19 Patients

Join EMGuideWire team as they listen in to EM Residency Conference at Carolinas Medical Center (in Charlotte, NC) and learn from Emily MacNeill, MD as she discusses "What Happens When a Disease Management System Crashes into a Public Health Crisis."

Healthcare Disparities and COVID Pandemic

Join the EMGuideWire team as they learn from one of the world's foremost experts in neurologic emergencies, Dr. Andrew Asimos. This episode will address the Neurologic Manifestations and Complications of the COVID-19 Infection.

Neurologic Manifestations and Complications of COVID-19

Join the EMGuideWire team as they listen to Dr. Geib discuss how to recognize and manage Hydroxychloroquine toxicity, which may become more prevalent during the current COVID-19 pandemic.

Hydroxychloroquine Toxicity

Join the EMGuideWire team as they learn from Critical Care fellow, Dr. Russell Trigonis while he addresses the important aspects of managing ARDS in patients with COVID-19 infections.

ARDS Management during COVID 19

OB Trauma Core Concepts Physiologic changes of pregnancy: physiologic anemia, decreased SVR, increased HR, increased RR, and pelvic vessel engorgement  Traumatic complications: placental abruption, preterm labor (PTL), uterine rupture, and pelvic fx Abruption triad = abd pain, large for dates uterus, vaginal bleeding Perform cervical check to eval for PTL Obtain Type and Screen and KB test Give Rhogam if mom is Rh neg. 50 mcg if 12 wks Check fetal HR after E-FAST, nml is 120-160     -Travis Barlock

Trauma and Pregnancy

Join the EMGuideWire Crew from CMC EM Residency Program as they discuss Ludwig's Angina and the management Priorities!!! BACKGROUND Angina = “Strangling” Bilateral infection of submental, submandibular, and sublingual spaces 70-85% of cases arise from odontogenic source Periapical abscesses of mandibular molars Piercings (frenulum) URI more common cause in children Source of infection often polymicrobial Most commonly viridans; also Staphylococcus and Bacteroides species Patients usually 20-60 years-old; more common in males1 Mortality in treated Ludwig’s Angina = 8%7 ***Airway compromise = leading cause of death8 Who Is At Risk? Diabetes mellitus Chronic alcohol abuse IVDA HIV/AIDS Malnutrition Poor oral hygiene Smokers Anatomy & Pathophysiology Mylohyoid subdivides submandibular space: Sublingual space Submaxillary (submylohyoid) space Infection extends posteriorly and superiorly, elevating tongue against hypopharynx If left untreated, can extend inferiorly to retropharyngeal space and into superior mediastinum3 Clinical Signs & Symptoms Dysphagia Odynophagia Trismus Edema of upper midline neck and floor of mouth Raised tongue "Woody" or brawny texture to floor of mouth with visible swelling and erythema Late Findings Drooling Tongue protrusion Trismus Dysphonia Cyanosis Acute laryngospasm Stridor Patients may demonstrate signs of systemic toxicity → fever, tachycardia, and hypotension How Do I Make the Diagnosis? Clinically! Consider CT head/neck Can help evaluate extent of infection if clinical situation persists CBC Chemistry Lactate Blood Cultures Management Emergent ENT/OMFS consult for I&D in OR and extraction of dentition if source is dental abscess Airway Management Intubation will be VERY difficult due to trismus and posterior pharyngeal extension Ideal situation = awake fiberoptic intubation in OR ALWAYS have a surgical airway ready as your back up plan Blind insertion devices (e.g. intubating LMA) are NOT recommended Management - Antibiotics Must cover typical polymicrobial oral flora Immunocompetent 3rd-generation Cephalosporin + (Clindamycin or Metronidazole) Ampicillin/Sulbactam Penicillin G + Metronidazole Clindamycin (allergic to penicillin) Immunocompromised → *Need MRSA and GNR coverage!3 Cefepime + Metronidazole Meropenem Piperacillin-tazobactam Add Vancomycin if concern for MRSA risk factors Steroids Dexamethasone 10 mg IV Thought to chemically decompress for airway protection and increase antibiotic penetration6 Nebulized epinephrine Resuscitation and pain control Complications Intracranial infections (e.g. CST, brain abscess) IJ thrombophlebitis (Lemirre’s Syndrome) Mediastinitis Mandibular osteomyelitis Empyema Pearls Three characteristics of Ludwig’s angina can be remembered as the 3 Fs: Feared Often Fatal Rarely Fluctuant ABCs—Sit upright Early notification of ENT/OMFS and anesthesia to facilitate definitive airway management Arrange for the patient to be admitted to ICU Priorities!!! Secure the airway EARLY! Prepare and be ready for a difficult airway — expect that the patient will require a surgical airway Prevent the development of septic shock and multi-organ failure — give antibiotics early References Lin HW, O’Neil A, Cunningham MJ. Ludwig’s Angina in the Pediatric Population. Clin Pediatr (Phila) 2009;48:583-7. Baez-Pravia, Orville V. et al. “Should We Consider IgG Hypogammaglobulinemia a Risk Factor for Severe Complications of Ludwig Angina?: A Case Report and Review of the Literature.” Medicine. 2017;96(47):e8708. Pandey M, Kaur M, Sanwal M, Jain A, Sinha SK. Ludwig’s Angina in children anesthesiologist’s nightmare: Case series and review of literature. J Anaesthesiol Clin Pharmacol. 2017 Jul-Sep;33(3):406-409. Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig’s Angina Ann Maxillofac Surg. 2015 Jul-Dec;5(2):168-73. Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol 110: 1051, 2001. Saifeldeen K, R Evans. Ludwig’s Angina. Emerg Med J 2004; 21: 242-243 Nanda N, Zalzal HG, Borah Gl. Negative-Pressure Wound Therapy for Ludwig’s Angina: A Case Series.Plast Reconstr Surg Glob Open2017 Nov 7;5(11):e1561. Pak S, Cha D, Meyer C, Dee C, Fershko A.Ludwig’s Angina. Cureus. 2017 Aug 21;9(8):e1588.  

Ludwig's Angina

Join the EMGuideWire team as they discuss Superior Vena Cava Syndrome! Shownotes: Definition: Any condition leading to obstruction of blood flow through the SVC Pathophysiology: Pathology in adjacent anatomy (lung, lymph node, thymus, mediastinum) or within the SVC itself obstructs venous return to the right atrium. As the SVC is compressed, venous collaterals form alternative pathways returning blood to the right atrium which can dilate over several weeks. As a result, upper body venous pressure increases, which in extreme cases lead to airway congestion and venous cerebrovascular congestion and edema. Hemomdynamic compromise is most often by direct compression of the heart, not from SVC obstruction. Risk factors: Indwelling device through the SVC (Central line, dialysis catheter, pacemaker) Lung cancer Lymphoma Thymoma Presentation: Signs – plethoric appearance, dilated neck and chest veins, swollen face/neck/chest Symptoms – congestive symptoms (head fullness, swelling), cardiopulmonary symptoms (chest pain, dyspnea, stridor, hoarseness), and neurologic symptoms (headache, confusion, obtundation, visual disturbances) Work-up: Is the patient unstalbe? Do they have severe SVC? If yes, secure airway, support breathing, support circulation Consult vascular/cardiothoracic surgery If patient is stable, then: Confirm diagnosis and evaluate for malignant obstruction CBC, CMP, PT/INR, CXR, CT chest w/contrast Does the patient have a malignant obstruction or thrombosis? Yes -> consult heme/onc and admit No -> observe in ED     References: García Mónaco R, Bertoni H, Pallota G, et al. Use of self-expanding vascular endoprostheses in superior vena cava syndrome. Eur J Cardiothorac Surg 2003; 24:208. Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore) 2006; 85:37. Schraufnagel DE, Hill R, Leech JA, Pare JA. Superior vena caval obstruction. Is it a medical emergency? Am J Med 1981; 70:1169. Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med 2007; 356:1862.

SVC Syndrome

Join the faculty and residents of Carolinas Emergency Medicine Residency Program, one of the oldest programs in the country, as they explore some of the Core Concepts of Emergency Medicine as well as many of the niche environments of this important arena of specialty care.

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