resuscitation and critical care medicine

Episode 69 Obesity Emergency Management

Current estimates of the prevalence of obesity are that a quarter of adult Canadians and one third of Americans are considered obese with approximately 3% being morbidly obese. With the proportion of patients with a BMI>30 growing every year, you’re likely to manage at least one obese patient on every ED shift. Obese patients are at high risk of developing a host of medical complications including diabetes, hypertension, coronary artery disease, peripheral vascular disease, biliary disease, sleep apnea, cardiomyopathy, pulmonary embolism and depression, and are less likely compared to non-obese adults to receive timely care in the ED. Not only are these patients at higher risk for morbidity and mortality, but obesity emergency management is complicated by the patient’s altered cardiopulmonary physiology and drug metabolism. This can make their acute management much more challenging and dangerous. To help us gain a deeper understanding of the challenges of managing obese patients and elucidate a number of important differences as well as practical approaches to obesity emergency management, we welcome Dr. Andrew Sloas, the founder and creator of the fantastic pediatric EM podcast PEM ED, Dr. Richard Levitan, a world-famous airway management educator and innovator and Dr. David Barbic a prominent Canadian researcher in obesity in emergency medicine from University of British Columbia....

Best Case Ever 39 – Airway Strategy & Mental Preparedness in EM Procedures with Richard Levitan

I caught up with airway educator, innovator and self-described enthusiast Dr. Richard Levitan at SMACC in Chicago this past June. In this Best Case Ever on Airway Strategy and Mental Preparedness in EM Procedures, Dr. Levitan uses a great save of his in a penetrating trauma case as a basis for discussion on mental preparedness and how we've been thinking about our general approach to emergency procedures the wrong way. Rather than fixating on the final goal of a procedure, which can often be daunting and lead us astray, he suggests a methodical incrementalized and compartmentalized approach to EM procedures that reduces stress and fear, improves confidence and enhances success. He runs through several examples including intubation, cricothyrotomy and initial approach to hypoxia to explain his Simple Incremental Approach to EM Procedures. Could this be a paradigm shift in the way we think about procedures in EM?....

Best Case Ever 36 Tracheo-innominate Fistula

In this Best Case Ever with Dr. Scott Weingart, the brains behind EMcrit.org, we hear the devastating story of a tracheostomy gone bad. Dr. Weingart shares with us what he has learned about how to manage massive hemoptysis in tracheostomy patients, and in particlar, a step-wise approach to managing a tracheo-innominate fistula. We discuss the balance between providing maximal aggrressive critical care while maintaining a deep respect for the risks associated with the procedures we perform. Recorded at North York General's EM Update Conference 2015.

Episode 64 Highlights from Whistler’s Update in EM Conference 2015 Part 2

In this Part 2 of EM Cases' Highlights from Whistler's Update in EM Conference 2015 Dr. David Carr gives you his top 5 pearls and pitfalls on ED antibiotic use including when patients with sinusitis really require antibiotics, when oral antibiotics can replace IV antibiotics, how we should be dosing Vancomycin in the ED, the newest antibiotic regimens for gonorrhea and the mortality benefit associated with antibiotic use in patients with upper GI bleeds. Dr. Chris Hicks gives you his take on immediate PCI in post-cardiac arrest patients with a presumed cardiac cause and The Modified HEART Score to safely discharge patients with low risk chest pain.

Best Case Ever 35: Taking Action in Emergency Medicine

In anticipation of our series of podcasts on Diagnostic Decision Making with Dr. Walter Himmel, Dr. Chris Hicks and Dr. David Dushenski we have Dr. Hicks presenting his Best Case Ever. Taking action in Emergency Medicine requires not only careful consideration of the best evidence, the experience of the clinician, the patient's values and the system that you work in, but also the will to act. Dr. Hicks describes a case of a patient who suffers a cardiac arrest, where the diagnosis is quite obvious to everyone in the room (and the required action is as well), yet a delay in treatment occurs nonetheless.

Episode 61 Whistler’s Update in EM Conference 2015 Highlights Part 1

This EM Cases episode is Part 1 of The Highlights of The University of Toronto, Divisions of Emergency Medicine, Update in EM Conference from Whistler 2015 with Paul Hannam on Pearls and Pitfalls of Intraosseus Line Placement, Anil Chopra on who is at risk and how to prevent Contrast Induced Nephropathy, and Joel Yaphe on the Best of EM Literature from 2014, including reduction of TMJ dislocations, the TRISS trial (on transfusion threshold in sepsis), PEITHO study for thrombolysis in submassive PE, Co-trimoxazole and Sudden Death in Patients Receiving ACE inhibitors or ARBs, the effectiveness and safety of outpatient Tetracaine for corneal abraisons, chronic effects of shift work on cognition and much more...

Best Case Ever 31: Emergency Pericardiocentesis

On this EM Cases Best Case Ever, Andrew Sloas, the brains behinds the fabulous PEM-ED podcast tells the tale of a pericardiocentesis gone bad and what he learned from it. Emergency pericardicentesis can be life saving, but it also carries risks. Dr. Sloas reviews the steps to take to ensure that the pericardiocentesis needle is the the correct place to minimize the risk of intubating the right ventricle of the heart. A discussion of errors of omission and ones of commission follows.... [wpfilebase tag=file id=540 tpl=emc-play /] [wpfilebase tag=file id=541 tpl=emc-mp3 /]

Episode 55: Fluids in Sepsis, Post-intubation Analgesia and Sedation

In this second part of the Weingart-Himmel Sessions on critical care pearls for the community ED on the EM Cases podcast, we discuss the many controversies and recent changes in fluid management in severe sepsis and septic shock. With the recently published ARISE trial, and some deviations from Early Goal Directed Therapy, we are changing the way we think about fluids in sepsis: the type of fluid, the volume of fluid, the rate of fluid administration, the timing of introducing vasopressors and the goals of fluid resuscitation. In the next section of the podcast we discuss the PAD mnemonic for post-intubation analgesia and sedation, the prevention of delirium, and medication choices to minimize time on the ventilator, and improve prognosis.

Episode 54: Preoxygenation and Delayed Sequence Intubation

Hot on the heels of Dr. Weingart's latest publication in the Annal of EM on Preoxygenation & Delayed Sequence Intubation, we have Dr. Weingart, perhaps the world's most influential critical care educator, and Dr. Walter Himmel, 'The Walking Encyclopedia of EM' discussing how the community ED doc can use preoxygenation, apneic oxygenation and delayed sequence intubation to help improve airway management knowledge and skills. Whether you work in a rural setting or a big urban community hospital, Dr. Himmel and Dr. Weingart explain how these concepts and skills are easily adaptable to your work environment. We introduce the Triple 15 Rule for preoxygenation as a memory aid that will help you the next time you're faced with a critically ill patient who's oxygen saturation isn't good enough on a non-rebreather.

Episode 50 Recognition and Management of Pediatric Sepsis and Septic Shock

Kids aren't little adults. Pediatric sepsis and septic shock usually presents as 'cold shock' where as adult septic shock usually presents as 'warm shock', for example. In this episode, a continuation of our discussion on Fever from with Ottawa PEM experts, Sarah Reid and Gina Neto, we discuss the pearls and pitfalls in the recognition and management of pediatric sepsis and septic shock. We review the subtle clinical findings that will help you pick up septic shock before it's too late as well as key maneuvers and algorithms to stabilize these patients. We cover tips for using IO in children, induction agents of choice, timing of intubation, ionotropes of choice, the indications for steroids in septic shock, and much more.....

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