Always On EM - Mayo Clinic Emergency Medicine

Whether or not emergency physicians believe that patients with thoughts of self-harm belong in the ED, they are coming to your ED anyway. According to the Centers for Disease Control, ED visit rates for nonfatal self-harm increased 42% among persons 10 years or older, and visits for suicidal ideation, self-directed violence, or both increased 25.5% from 2017-2018. That’s an increase of more than 1% per month pre-COVID. This solutions-oriented talk will discuss some of the science behind suicide prevention in the ED, and will present techniques that you can use to reduce risk in your ED.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com

Dr. Suraj Yalamuri, Mayo Clinic Anesthesiology Critical Care and Cardiovascular Medicine Consultant, joins Alex and Finch to talk about the fundamentals of ECMO and ECPR. This is a great way to get caught up on this emerging science so that you'll be ready to provide the best resuscitative care for your patients when your system is ready too. 

Dr. Leff shares, in her senior resident capstone presentation, a primer on humanitarian efforts, what are basic principles of aid, how to identify the key health needs of populations affected by crises and how EM clinicians can respond to those needs with the greatest impact. She will discuss how to engage responsibly and to anticipate how humanitarianism will develop and adapt in the future to improve responsiveness. 

Dr. Mike Olson, former EM PA and now ENT attending sits down to talk about epistaxis with Alex and Venk. We go through a pragmatic approach to epistaxis, discuss some nuance cases including telangiectasia, hypertension, and anticoagulation.  interventions are key, what patients are most likely to suffer a bad outcome and more. CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Ingason AB, et al. Warfarin is associated with higher rates of epistaxis compared to direct oral anticoagulants: a nationwide propensity score-weighted study. J Intern Med. 2022 Sep;292(3):501-511 Thomg JF, et al. A prospective comparative study to examine the effects of oral diazepam on blood pressure and anxiety levels in patients with acute epistaxis. Journal of Laryng & Otol. 2007. (121)124-129 Terakura M et al. Relationship between blood pressure and persistent epistaxis at the emergency department: a retrospective study. J Am Soc Hypertens. 2012 Jul(4):291-295 Lee CJ, et al. Evaluation of the relationship between blood pressure control and epistaxis resource after achieving effective hemostasis in the emergency department. J Acute Med. 2020 mar 1;10(1)27-39  

Dr. Casey Clements spent two hours breaking down the history and influences in sepsis care over the past three decades and going through the best practices in today's emergency medicine. This is the second part of the two part series. Do you know how Sepsis is defined currently? What is the difference between SEP - 1 and surviving sepsis campaign? What is the role of steroids or vitamin C? Can you resuscitate these patients with albumin? These and so many more questions will be answered in this two part series. We review the PROCESS, PROMISE, and ARISE trials and provide pragmatic approach to your septic patients.  So join Venk like vancomycin, and Alex (aka Zosyn) and Casey "not-cidal" Clements in these amazing episodes.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Intravascular volume assessment Azadian M, Win S, Abdipour A, et al. Mortality benefit from the passive leg raise maneuver in guiding resuscitation of septic shock patients: A systematic review and meta-analysis of randomized trials. J Intensive Care Med. 2022 May;37(5):611-617 Spiliotaki E, Saranteas T, Moschovaki N, et al. Inferior vena cava ultrasonography in the assessment of intravascular volume status and fluid responsiveness in the emergency department and intensive care unit: a critical analysis review. J Clin Ultrasound. 2022 Jun;50(5):733-744   Chest radiography paper referenced Poku JK, Bellamkonda-Athmaram VR, Bellolio F, Nestler DM, Stiell IG, Hess EP. Failure of prospective validation and derivation of a refined clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome. Acad Emerg Med. 2012 Sep;19(9):E1004-10   Albumin Caironi P, Tognoni G, Masson S, Fumagalli R, Presenti A, Romero M, Fanizza C, Caspani L, Faenza S, Grasselli G, Iapichino G, Antonelli M, Parrini V, Fiore G, Latini R, Gattinoni L, ALBIOS Study Investigators. Albumin Replacement in patients with severe sepsis or septic shock. NEJM. 2014;370(15):1412 Xu JY, Chen QH, Xie JF, Pan C, Liu SQ, Huang LW, Yang CS, Liu L, Huang YZ, Guo FM, Yang Y, Qiu HB. Comparison of the effects of albumin and cyrstalloid on mortality in adult patients with severe sepsis and septic shock: a meta-analysis of randomized clinical trials. Crit Care. 2014;18(6):702 Jiang L, Jiang S, Zhang M, Zheng Z, Ma Y. Albumin versus other fluids for fluid resuscitation in patients with sepsis: A meta-analysis. PloS One. 2014;9(12):e114666   Unbundling studies ProCESS Trial: ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, PIke F, Terndrup T, Wang HE, Hou PC, LoVecchio F, Filbin MR, Shapiro NI, Angus DC. A randomized trial of protocol based care for early septic shock. NEJM  2014;370(18):1683 ProMISE Trial: Mouncey PR, Osborn ™, Power GS, Harrison DA, Sadique MZ, Grieve RD, Jahan R, Harvey SE, Bell D, Bion JF, Coats TJ, Singer M, Young JD, Rowan KM, ProMISe Trial Investigators. Trial of early, goal directed resuscitation for septic shock. NEJM 2015;372(14):1301 ARISE Trial: ARISE investigators, ANZICS Clinical Trials Group, Peake SL, Delaney A, Bailey M, Bellomo R, Cameron PA, Cameron PA, Cooper DJ, Higgins AM, Holdgate A, Howe BD, WEbb SA, Williams P. Goal-directed resuscitation for patients with early septic shock. NEJM 2014;371(16):1496 Angus DC, Barnato AE, Bell D, Bellomo R, Chong CR, Coats TJ, Davies A, Delaney A, Harrison DA, Holdgate A, Howe B, Huang DT, Iwashyna T, Kellum JA, Peake SL, Pike F, Reade MC, Rowan KM, Singer M, Webb SA, Weissfeld LA, Yealy DM, Young JD. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS, and ProMISE investigators. Intensive Care Med. 2015 SEp;41(9):1549-60 PRISM Investigators. Early Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis. NEJM 2017 Lu Y, Zhang H, Teng F, Xia WJ, SUn GX, Wen AQ. Early goal-directed therapy in severe sepsis and septic shock: A meta-analysis and Trial sequential analysis of randomized controlled trials. J Intensive Care Med. 2018;33(5):296   Vitamin C Sevransky JE, et al. Effect of vitamin C, thiamine, and hydrocortisone on ventilator- and vasopressor-free days in patients with sepsis: The VICTAS randomized clinical trial. JAMA. 2021 Feb 23;325(8):742-750  

Dr. Casey Clements spent two hours breaking down the history and influences in sepsis care over the past three decades and going through the best practices in today's emergency medicine. Do you know how Sepsis is defined currently? What is the difference between SEP - 1 and surviving sepsis campaign? What is the role of steroids or vitamin C? Can you resuscitate these patients with albumin? These and so many more questions will be answered in this two part series. So join Venk like vancomycin, and Alex (aka Zosyn) and Casey "not-cidal" Clements in these amazing episodes.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS SOFA Score: Vincent JL, MOreno R, Takala J, et al. The SOFA (Sepsis-related organ failure assessment) score to describe organ dysfunction / failure. On Behalf of the working group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996 Jul;22(7):707-10 Vincent JL, de Mendonca A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction / failure in intensive care units: results of a multicenter, prospective study. Working group on ‘sepsis-related problems’ of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26(11):1793-1800 Ferreira FL, Bota DP, Bross A, Merlot C, Vincent JL. Serial evaluation of the SOFA score to predict outcomes in critically ill patients. JAMA. 2001 Oct 10;286(14):1754-8 Cardenas-Turanzas M, Ensor J, Wakefield C, Zhang K, Wallace SK, Price KJ, Nates JL. Cross-validation of a sequential organ failure assessment score-based model to predict mortality in patients with cancer admitted to the intensive care unit. J Crit Care. 2012 Dec;27(6):673-80 qSOFA score Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):762-774 Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a new definition and assessing new clinical criteria for septic shock: For the Third International Consensus Definitions for Sepsis and SEptic Shock (Sepsis-3). JAMA. 2016;315(8):775-787 Freund Y, Lemachatti N, Krastinova E, et al. Prognostic accuracy of Sepsis-3 Criteria for in-hospital mortality among patients with suspected infection presenting to the emergency department. JAMA. 2017;317(3):301-308 Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit. JAMA. 2017;317(3):290-300 Comparing Prognostic scores Henning DJ, Puskarich MA, Self WH, Howell MD, Donnino MW, Yealy DM, Jones AE, Shapiro NI. An Emergency Department validation of the SEP-3 Sepsis and Septic Shock definitions and comparison with 1992 consensus definitions. Ann Emerg Med. 2017 Oct;70(4):544-552 IDSA concern Rhee C, Chiotos K, Cosgrove SE, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Strich JR, Winslow DL, Klompas M. Infectious diseases society of america position paper: Recommended revisions to the National Severe Sepsis and Septic Shock early management bundle (SEP-1) Sepsis Quality Measure. Clin Infect Dis. 2021 Feb 16;72(4):541-552 About Barcelona Declaration Slade E, Tamber PS, Vincent JL. The Surviving Sepsis Campaign: raising awareness to reduce mortality. Crit Care. 2003;7:1-2 1- hour surviving sepsis bundle guidance Freund Y, Khoury A, Mockel M, et al. European Society of Emergency Medicine position paper on the 1-hour sepsis bundle of the Surviving Sepsis Campaign: expression of concern. Eur J Emerg Med. 2019 Aug;26(4):232-233 Early Goal Directed Therapy Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM. 2001 Nov 8;345(19):1368-77 SEP - 1 Quality Measure National Quality Forum Measure submission and evaluation worksheet 5.0 for NQF #0500 Severe Sepsis and Septic Shock: Management Bundle, last updated Date: Oct 05, 2012. Website link Accessed 01-31-2024: https://www.qualityforum.org/Projects/i-m/Infectious_Disease_Endorsement_Maintenance_2012/0500.aspx  National Quality Forum: NQF Revises Sepsis Measure. Website link accessed 01-31-2024: https://www.qualityforum.org/NQF_Revises_Sepsis_Measure.aspx  Faust JS, Weingart SD. The Past, Present, and Future of the Centers for Medicare and Medicaid Services Quality Measure SEP-1 - the early management bundle for severe sepsis / septic shock. Emerg Med Clin N Am. 2017; 35:219-231 Affordable care act Patient Protection and Affordable Care Act, Public Law 148, U.S. Statutes at Large 124 (2010):119-1024. Website link accessed 01-31-2024: https://www.govinfo.gov/app/details/STATUTE-124/STATUTE-124-Pg119/summary.  Fluids for sepsis in concerning populations Pence M, Tran QK, Shesser R, Payette C, Pourmand A. Outcomes of CMS-mandated fluid administration among fluid-overloaded patients with sepsis: A systematic review and meta-analysis. Am J Emerg Med. 2022 May:55:157-166 Zadeh AV, Wong A, Crawford AC, Collado E, Larned JM. Guideline-based and restricted fluid resuscitation strategy in sepsis patients with heart failure: A systematic review and meta-analysis. Am J Emerg Med. 2023 Nov:73:34-39   WANT TO WORK AT MAYO? EM Physicians: https://jobs.mayoclinic.org/emergencymedicine EM NP PAs: https://jobs.mayoclinic.org/em-nppa-jobs   Nursing/Techs/PAC: https://jobs.mayoclinic.org/Nursing-Emergency-Medicine EMTs/Paramedics: https://jobs.mayoclinic.org/ambulanceservice All groups above combined into one link: https://jobs.mayoclinic.org/EM-Jobs  

In this chapter, Dr. Dougie Moss, final year EM resident presents his Capstone presentation on best charting practices to match reimbursement to the care we deliver. Take a listen to better understand the new billing expectations of our documentation.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com

Alex and Venk talk through a previous case where they care for a young person with meningococcemia on a night shift. We review the disease, what to watch for, how to treat it, and go over some of the residue after being part of a case like this. We also review some of the considerations regarding ECMO for severe sepsis.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Heckenberg SG, et al. Clinical features, outcome and meningococcal genotype in 258 adults with meningococcal meningitis: a prospective cohort study. Medicine (Baltimore) 2008. 87(4):185 Brechot N, Hajage D, et al. Venoarterial extracorporeal membrane oxygenation to rescue sepsis-induced cardiogenic shock: a retrospective, multicentre, international cohort study. Lancet 2020. 396(10250)545-552 Ling RR, Ramanathan K, et al. Venoarterial extracorporeal membrane oxygenation as mechanical circulatory support in adult septic shock: a systematic review and meta-analysis with individual participant data meta-regression analysis. Crit Care 2021. Jul 14;25(1):246   WANT TO WORK AT MAYO? EM Physicians: https://jobs.mayoclinic.org/emergencymedicine EM NP PAs: https://jobs.mayoclinic.org/em-nppa-jobs   Nursing/Techs/PAC: https://jobs.mayoclinic.org/Nursing-Emergency-Medicine EMTs/Paramedics: https://jobs.mayoclinic.org/ambulanceservice All groups above combined into one link: https://jobs.mayoclinic.org/EM-Jobs

It is no surprise that outcomes are poor for patients who already meet one definition for 'death' even before the point of their first medical contact. But for nearly half of certain patients with out-of-hospital cardiac arrest, good neurologic outcomes can be achieved. And while patients with in-hospital cardiac arrest are also very likely to suffer a poor outcome, there is some reason to believe that some out-of-hospital cardiac arrest patients might have a better chance of survival. During this discussion, we will discuss why this might be, while also challenging assumptions about topics including epinephrine, airway management, and the risks and benefits of transporting patients in cardiac arrest. We will also look to future directions in cardiac arrest management.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com

This chapter we talk with Dr. Henry Schiller, trauma surgeon and professor of surgery at Mayo Clinic, about a variety of hematomas including Morel Lavellee lesions, retroperitoneal hematomas, rectus sheath and more! Alex even gets to ask a question about REBOA that he has been hoping to do for a long time.  CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Nickerson TP, Zielinski MD, Jenkins DH, Schiller HJ. The Mayo Clinic Experience with Morel-Lavallee lesions: Establishment of a practice management guideline. J Trauma Acute Care Surg. 2012. Vol 76, Number 2 493-497 Demetriades D, Chan LS, Velmahos G, Berne TV, Cornwell III EE, Belzberg H, Asensio JA, Murray J, Berne J, Shoemaker W. TRISS methodology in trauma: the need for alternatives. British Journal of Surgery 1998, 85,379-384 Meyer DM, Jessen ME, Grayburn PA. Use of echocardiography to detect occult cardiac injury after penetrating thoracic trauma: A prospective study. J Trauma. 1995 Nov;39(5):902-7      

In this episode, Dr. Heather Murray, from Queen's University Department of Emergency Medicine presents the landscape of diagnostic errors in emergency medicine from the perspective of why they might occur, what can be done when they happen, and how we might minimize them in the future.    CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com   REFERENCES ARHQ report and responses: December 2022, AHRQ (Agency for Healthcare Research and Quality) released a systematic review on diagnostic error in the ED. https://effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-258-diagnostic-errors.pdf Letter from many ED organizations: Multi-Organizational Letter Regarding AHRQ Report on Diagnostic Errors in the Emergency Department December 14, 2022 Published critical appraisal of report: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10121120/pdf/ms120_p0114.pdf JAMA commentary Feb 2023 “Misdiagnosis in the ED: Time for a System Solution” Misdiagnosis in the Emergency Department: Time for a System Solution | Health Care Safety | JAMA Recovering from error: ARHQ summary on recovery after error Second Victims: Support for Clinicians Involved in Errors and Adverse Events | PSNet ARHQ Commentary – after error:How Do Providers Recover From Errors? | PSNet Clinician Peer Support Program after adverse events – implementation Supporting Clinicians after Adverse Events: Development of a Clinician Peer Support Program - PMC Scott SD, Hirschinger LE, Cox KR, McCoig M, Hahn-Cover K, Epperly KM, Phillips EC, Hall LW. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010 May;36(5):233-40. Caring for our own: deploying a systemwide second victim rapid response team   General resources on Diagnostic Error: Schiff JAMA Network Open 2021Characteristics of Disease-Specific and Generic Diagnostic Pitfalls: A Qualitative Study | Health Policy | JAMA Network Open Monteiro et al. 2020 Review “The enduring myth of generalisable skills.” https://asmepublications.onlinelibrary.wiley.com/doi/full/10.1111/medu.13872 Book – Improving Diagnosis in Health Care (chapter 9) The Path to Improve Diagnosis and Reduce Diagnostic Error   Cognitive biases: MDs were asked to reflect on a serious error and given some education on cognitive biases: Watari, T.; Tokuda, Y.; Amano, Y.; Onigata, K.; Kanda, H. Cognitive Bias and Diagnostic Errors among Physicians in Japan: A Self Reflection Survey. Int. J. Environ. Res. Public Health 2022, 19, 4645. Cognitive Bias and Diagnostic Errors among Physicians in Japan: A Self-Reflection Survey Anchoring Bias and strategies for overcoming: Anchoring Bias With Critical Implications | PSNet "Give me a break!" A systematic review and meta-analysis on the efficacy of micro-breaks for increasing well-being and performance: Albulescu P, Macsinga I, Rusu A, Sulea C, Bodnaru A, et al. (2022) "Give me a break!" A systematic review and meta-analysis on the efficacy of micro-breaks for increasing well-being and performance. PLOS ONE 17(8): e0272460. "Give me a break!" A systematic review and meta-analysis on the efficacy of micro-breaks for increasing well-being and performance | PLOS ONE   Better teams in EM: Purdy E, Borchert L, El-Bitar A et al “Psychological safety and Emergency Medicine team performance: a mixed methods review.” EM Australasia 2023;35:456-465 Psychological safety and emergency department team performance: A mixed‐methods study - Purdy Ottawa M+M rounds framework: Enhancing the Quality of Morbidity and Mortality Rounds: The Ottawa M&M Model - Calder - 2014 - Academic Emergency Medicine - Wiley Online Library   Selected references for artificial intelligence in medicine: AI chatbot in JAMA Internal Medicine Comparing Physician and Artificial Intelligence Chatbot Responses to Patient Questions Posted to a Public Social Media Forum | Health Informatics | JAMA Internal Medicine AI in Health Care NEJM podcast Is Medicine Ready for AI? — ITT Episode 6 | NEJM AI clinical prediction (systematic review 2022) Artificial Intelligence for the Prediction of In-Hospital Clinical Deterioration: A Systematic Review - PMC Lee P, Bubeck S, Petro J. Benefits, limits and risks of GPT-4 as an AI chatbot for medicine. NEJM 2023;388:1233-1239 Benefits, Limits, and Risks of GPT-4 as an AI Chatbot for Medicine | NEJM  

Neonatal fever can raise the temperature of the entire clinical pod along with the baby, but it doesnt have to. Join as Dr. Meghan Cain, chair of the division of pediatric and adolescent emergency medicine at Mayo Clinic, talks through the nuances of evaluating fever concerns in neonates of different ages and risk profiles and empowers you to be cool as a cucumber in these situations. CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Pantell RH, Roberts KB, Adams WG, Dreyer BP, Kuppermann N, O’Leary ST, Okechukwu K, Woods Jr CR. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics. 2021 Aug;148(2):e2021052228 Powell EC, Mahajan PV, Roosevelt G, Hoyle Jr JD, Gattu R, Cruz AT, Rogers AJ, Atabaki S, Jaffe DM, Casper TC, Ramilo O, Kuppermann N. Epidemiology of bacteremia in febrile infants aged 60 days and younger. Ann Emerg Med. 2018 Feb;71(2):211-216 Mahajan P, Browne LR, Levine DA, Cohen DM, Gattu R, Linaki JG, Anders J, Borgialli D, Vitale M, Dayan PS, Casper TC, Ramilo O, Kuppermann N. Risk of bacterial coinfections in febrile infants 60 days and younger with documented viral infections. J Pediatr. 2018 Dec:203:86-91.e2

So many people come to emergency departments with unexplained recurrent pains, fatigues, gastrointestinal symptoms and more - when there seems like no way we can help them, Dr. Mohabbat offers us some insight into what might be happening and how we can help be a positive experience in these patient's and family's lives. Listen to this grand rounds on Central Sensitization and be a better doctor for this large segment of the population. CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com  

Dr. Katie Young, co-director of the cardioobstetrics clinic here at Mayo Clinic sits down to talk about peripartum cardiomyopathy. This is something we will likely consider many times in our careers for patients with shortness of breath in and around late pregnancy. Find out what interventions are key, what patients are most likely to suffer a bad outcome and more. CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Gierula J, et al. Prospective evaluation and long-term follow up of patients referred to secondary care based upon natriuretic peptide levels in primary care. European Heart Journal – Quality of Care and Clinical Outcomes. 2019. 5, 218-224 Bay M, et al. NT-proBNP: A new diagnostic screening tool to differentiate between patients with normal and reduced left ventricular systolic function. Heart. 2003. 89,150-154 Dockree S, et al. Pregnancy reference intervals for BNP and NT-pro BNP – changes in natriuretic peptides related to pregnancy. Journal of Endocrine society. 2021. 5(7)1-9 Mueller C, et al. Heart failure association of the European society of cardiology practical guidance on the use of natriuretic peptide concentrations. European Journal of Heart Failure. 2019. 21, 715-731 Ravichandran J, et al. High-sensitivity cardiac troponin I levels in normal and hypertensive pregnany. American J of Medicine. 2019. 132,362-366 High sensitivity troponin T and I among pregnant women in the US – the National Health and Nutrition Examination Survey. JAMA Cardiology. 2023. 8(4)406-408 Tweet MS, et al. Spontenaoues Cardic Artey Dissection associated with pregnancy. Journal of the American College of Cardiology. 2017. 70,426-435 Baggish AL, et al. The differential diagnosis of an elevated amino-terminal Pro-B-Type Natriuretic Peptide level. Am J Cardiol. 2008. 101,43A-48A Lichtenstein DA, Meziere GA. Relevance of lung ultrasound in the diagnosis of acute Respiratory Failure – the Blue Protocol. Chest. 2008. 134,117-125 Smit MR, et al. Comparison of linear and sector array probe for handheld lung ultrasound in invasively ventilated ICU patients. Ultrasound in Med & Biol. 2020. 46(12)3249-3256 Haller EP, Nestler DM, Campbell RL, Bellamkond VA. Point-of-care ultrasound findings of acute pulmonary embolism: McConnell sign in the emergency medicine. JEM. 2014. 47(1)e19-e24 Halpern DG, et al. Use of medication for cardiovascular disease during pregnancy:JACC State of the Art Review. J Am Coll Cardiol. 2019. Feb, 73(4)457-476 Loyanga-Rendon RY, et al. Outcomes of patients with peripartum cardiomyopathy who received mechanical circulatory support. 2014. Circ Heart Failure. 7,300-309 Adedinsewo DA, et al. Detecting cardiomyopathies in pregnancy and the postpartum period with an electrocardiogram-based deep learning model. European Heart Journal – Digital Health. 2021. 2,586-596 Zieleskiewicz L., et al. Lung ultrasound-guided management of acute breathlessness during pregnancy. Anesthesia. 2013. 68,97-101 Balaceanu A. B-type natriuretic peptides in pregnant women with normal heart or cardiac disorders. Medical Hypotheses. 2018. 121,149-151

In this chapter, Dr. Alex Niven, renowned critical care physician and educator, provides a mirror for us to see our current state of emergency airway management - for its opportunities for improvement, innovations and best practices. This evidence fueled presentation is a must-listen for any emergency healthcare physician or provider. CONTACTS Youtube -https://www.youtube.com/@AlwaysonEM  X - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com

Dr. Nayantara Coelho-Prabhu, Mayo Clinic gastroenterologist specializing in the care of patients with gastrointestinal bleeding and endoscopy, talks through many aspects of acute GI bleeding. She helps to clarify the prioritization of medications, when to incorporate imaging, broadens our differentials for upper and lower GI bleeding, gives mindblowing advice on stool guiac testing and SO much more in this over-stuffed (or should we say constipated) chapter of Always on EM. There is also a special cameo from Dr. Luke Wood going over how to insert a Minnesota tube (esophageal balloon tamponade device)!   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com   RECOMMENDATION: Dieulafoy lesion video from New England Journal of Medicine: https://youtu.be/tzJQDen1nug?si=zOmywZ1VN3VvA004    REFERENCES: Drescher MJ, Stapleton S, Britstone Z, Fried J, Smally AJ. A call for reconsideration of the use of fecal occult blood testing in emergency medicine. Journal of Emerg Med. 2020. 58(1)54-58 Mathews BK, Ratcliffe T, Sehgal R, Abraham JM, Monash B. Fecal Occult Blood testing in hospitalized patients with upper gastrointestinal bleeding. Journal of Hospital Medicine. 2017. 12(7)567-569 Harewood GC, McConnell JP, Harrington JJ, Mahoney DW, Ahlquist DA. Detection of occult upper gastrointestinal bleeding: performance in fecal occult blood tests. Mayo Clin Proc. 2002 Jan;77(1):23-28 Blatchford O, et al. A risk score to predict need for treatment for upper gastrointestinal haemorrhage. Lancet 2000. Oct 14;356(9238):1318-21 Blatchford O, Davidson LA, Murray WR, Blatchford M, Pell J. Acute upper gastrointestinal haemorrhage in west of scotland: case ascertainment study. BMJ 1997. Aug 30;315(7107):510-4 Chen IC, Hung MS, Chiu TF, Chen JC, Hsiao CT. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding. Am J Emerg Med. 2007 Sep;25(7):774-9 Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021 May 1;116(5):899-917 Roberts I, Shakur-STill H, Afolabi A, et al. Effects of High-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 2020. 395(10241):1927-1936 Aziz M, Haghbin H, Gangwani MK, Weissman S, Patel AR, Randhawa MK, Samikanu LB, Alyousif ZA, Lee-Smith W, Kamal F, Nawras A, Howden CW. Erythromycin improves the quality of esophagogastroduodenoscopy in upper gastrointestinal bleeding: a network meta-analysis. Dig Dis Sci 2023. Apr;68(4):1435-1446 Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol 2022;00:1-17 Vigano GL, Mannucci PM, Lattuada A, Harris A, Remuzzi G. Subcutaneous desmopressin (DDAVP) shortens the bleeding time in uremia. Am J Hematol 1989. May;31(1):32-5 Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FL, Soares-Weiser K, Uribe M. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev 2010. Sep 8;2010(9):CD002907 Gao Y, Qian B, Zhang X, Liu H, Han T. Prophylactic antibiotics on patients with cirrhosis and upper gastrointestinal bleeding: A meta-analysis. PLoS One 2022. Dec 22;17(12):e0279496 Steffen R, Knapp J, Hanggi M, Iten M. Use of the REBOA catheter for uncontrollable upper gastrointestinal bleeding with hemorrhagic shock. Anaesthesiologie 2023. May;72(5):332-337 Sato M, Kuriyama A. Countering hemorrhagic shock due to duodenal variceal rupture with resuscitative endovascular balloon occlusion of the aorta. Am J Emerg Med 2023. Feb;64:204.e1-204.e3

Is healthcare more like an airplane, a flock of birds, or a mayonnaise? Why does it matter? In this talk, Dr. McNamara, emergency physician and patient safety champion, explores the question through the story of how she found herself at the intersection of complexity theory, safety science, and emergency medicine. She will discuss multiple perspectives on safety science, including specific strategies for clinicians to apply in their daily practice to survive amidst the complexity. CONTACTS X (formerly Twitter) - @AlwaysOnEM; @VenkBellamkonda; @ShannonOMac Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com  

Drs. Alex Finch and Venk Bellamkonda talk through tick related infectious diseases including Lyme Disease, Rocky Mountain Spotted Fever, Ehrlichiosis, Babesiosis and more! Tick related illnesses are prevalent this time of year, so take a moment to brush up on how to manage them. CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Society guidelines: United States CDC Tickborne diseases of the US Anaplasmosis - information for healthcare providers Babesiosis - resources for healthcare professionals Ehrlichiosis Lyme Disease RMSF A reference manual for healthcare providers 2017 American Academy of Pediatrics has several publications on babesiosis, borrelia infections other than Lyme, Ehrlichia, anaplasma, Lyme itself, RMSF Infectious Disease society of America Clinical practice guideline on diagnosis and management of babesiosis 2020 Canada Canadian pediatric society  Practice point on Lyme disease in Canada - focus on children 2021 Society of OB / Gyn of Canada Committee opinion for management of tick bites and Lyme disease during pregnancy 2020 Australia - New Zealand Australian government department of health released An Australian guideline on the diagnosis of overseas - acquired Lyme disease / borreliosis in 2015 Japan  choosing wisely Japan - Lyme disease 2018 India Department of health research - Indian council of medical research (ICMR) - guidelines for diagnosis and management of rickettsial diseases in India in 2015 UK National institute for health and care Excellence (NICE)  quality standards on Lyme disease 2019 Guideline on Lyme disease 2018 British Infection Association (BIA)

Dr. Kharmene Sunga, Mayo Clinic emergency medicine consultant physician, specializing in simulation, diversity equity and inclusion, and education shares a guide for how to communicate (both through listening and speaking) most effectively when it counts.    TEASER There's no place like the Emergency Department. Patients are in pain, scared, and anxious. Staff are distracted, fatigued, frustrated - and sometimes, well, also scared and anxious. How can Emergency Physicians speak to rise above the fray, to best care for patients, lead a team, and ensure that everyone feels heard? Join Dr. Kharmene Sunga as she discusses insights from sources ranging from medicine to business and even child psychology to cut through the proverbial noise.   CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com  

Ms Lisa Beck, assistant professor of nursing and a clinical nurse specialist in the department of physical medicine and rehabilitation, shares her experiences over a career in caring for persons with intrathecal baclofen pumps for managing spinal cord injury related spasticity. Baclofen related complications such as withdrawal and overdose can both be fatal and pump specific complications as well require timely expertise from the emergency care team – but not often discussed in emergency medicine. Check out the episode to learn more! CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Singh NK, Agarwal A, Salazar L, Henkle JQ. Osborn waves in hypothermia induced by baclofen overdose. BMJ Case Rep 2009; 2009. Sullivan R, Hodgman MJ, Kao L, Tormoehlen LM. Baclofen overdose mimicking brain death. Clin Toxicol (Phila) 2012;50:141 Alden TD, Lytle RA, Park TS, et al. Intrathecal baclofen withdrawal: a case report and review of the literature. Childs Nerv Syst 2002;18:522