『EM Pulse Podcast™』のカバーアート

EM Pulse Podcast™

EM Pulse Podcast™

著者： UC Davis Department of Emergency Medicine
無料で聴く

【Amazonプライム会員限定】今ならプレミアムプランが4か月 月額99円。

10月19日まで。※適用条件あり
Bringing research and expert opinion to the bedside2023 UC Davis Emergency Department 教育 衛生・健康的な生活 身体的病い・疾患
エピソード
  • Push Dose Pearls: Managing Severe TBI

    Push Dose Pearls: Managing Severe TBI
    2026/09/22
    Caring for patients with severe traumatic brain injury (TBI)—especially pediatric patients—is high-stakes and high-stress. In severe TBI, primary brain injury occurs at the moment of impact; our primary goal in the emergency department is preventing secondary brain injury caused by hypoxia, hypoperfusion, elevated intracranial pressure (ICP), seizures, hyperthermia, and dysglycemia. In this episode, ED Clinical Pharmacist Haley Burhans returns to walk us through key medications for the acute management of severe TBI. We’ll cover airway management, rapid sequence intubation (RSI) drug choices, hyperosmolar therapy, seizure prophylaxis, TXA, and post-resuscitation care. 1. Airway & Rapid Sequence Intubation (RSI) Optimizing oxygenation and ventilation is critical, as hypoxemia directly contributes to secondary brain injury. Selecting hemodynamically neutral agents is essential to maintain cerebral perfusion pressure (CPP). Induction Agents Etomidate (0.3 mg/kg, max 40 mg): Hemodynamically neutral, making it a reliable choice for TBI patients with unstable or uncertain blood pressures.Ketamine (1–2 mg/kg): Excellent option for borderline low or hypotensive patients. Historical concerns regarding ketamine-induced ICP spikes have been largely disproven; bolus doses <5 mg/kg do not cause sustained ICP elevations and offer valuable analgesia. Paralytics Succinylcholine (1.5 mg/kg TBW, max 200 mg): Preferred if an immediate post-intubation neurological exam is required by neurosurgery, given its short duration (~10–15 min).Rocuronium (1.0–1.2 mg/kg): Higher dosing ensures rapid onset. Preferred when securing the airway smoothly and keeping the patient still for immediate CT scanning is the priority. Note: Paralyzes the patient for 45–60 minutes, so obtain a baseline neuro exam first or have a plan for reversal if an early exam is needed. Pre-Medications (Lidocaine vs. Fentanyl) Lidocaine (1.5 mg/kg): Theoretically blunts airway-reflex-induced ICP spikes during intubation, but takes 2–5 minutes to reach peak effect and introduces cardiac risks in undifferentiated trauma patients. Generally omitted when rapid airway placement is required.Fentanyl (1–2 mcg/kg): Preferred pre-medication for hypertensive or tachycardic patients to blunt sympathetic surges and prevent ICP spikes during laryngoscopy. 2. Post-Intubation Sedation & Hemodynamic Support Hypotensive / Unstable: Push-dose Ketamine (1–2 mg/kg) provides deep sedation while preserving blood pressure.Hypertensive / Stable: Propofol infusion (Adults: ~40 mcg/kg/min; Pediatrics: ~60 mcg/kg/min due to faster metabolism) helps suppress ICP and optimize CPP.Pressors: If vasopressors are required to maintain target SBP (>100–110 mmHg depending on age), titrate carefully to clear hemodynamic goals. Avoid reflexively starting high-dose pressors if transient hypotension was primarily driven by hypoxia or cardiac arrest before airway placement. 3. Seizure Prophylaxis Post-traumatic seizures increase metabolic demand and elevate ICP. First-Line Agent: Levetiracetam (Keppra) is non-inferior to Phenytoin for preventing early post-traumatic seizures (within 7 days) and carries a significantly lower risk of cardiac side effects and agitation at standard loading doses.Dosing: Loading Dose: 20–25 mg/kg IV load (common adult loading dose is 20 mg/kg or a standard 1,000–2,000 mg IV dose).Maintenance: 25 mg/kg IV BID in pediatrics; 1,000 mg IV BID in adults (adjusted for renal function). 4. Hyperosmolar Therapy for Cerebral Edema When signs of impending herniation or acute ICP elevation are present: Hypertonic Saline (3% NaCl): Pediatrics: First-line agent at 2–5 mL/kg IV. Avoids the diuretic/hypovolemic risks associated with mannitol in volume-dependent pediatric patients.Adults: Strongly preferred over mannitol due to less rebound ICP elevation and easier administration (mannitol requires inline filters and can crystallize). Mannitol (0.5–1 g/kg): Alternative option in adults, but can cause osmotic diuresis, hypotension, and rebound ICP increases.Combining/Redosing: Avoid giving both hypertonic saline and mannitol simultaneously as initial therapy—if the patient deteriorates 30 minutes later, therapeutic options are exhausted. Hypertonic saline is easier to redose safely after monitoring serum sodium levels (peak effect around 1 hour). 5. Role of Tranexamic Acid (TXA) Isolated TBI in Adults: The CRASH-3 trial showed potential 30-day mortality benefits for mild-to-moderate TBI within 3 hours of injury, but limited clear benefit in isolated severe TBI. If a severe TBI is an isolated injury, routine TXA push is not strongly advocated if it delays primary line access for other resuscitation meds.Polytrauma / Pediatrics: If TBI is part of multi-trauma or severe pediatric trauma within 3 hours of injury, TXA is appropriate as part of overall trauma resuscitation protocols. 6. Critical ED Targets & Common Pitfalls Temperature Management: Target strict ...
    続きを読む 一部表示
    23 分
  • Blocking the Pain: Ultrasound Guided Nerve Blocks in the ED

    Blocking the Pain: Ultrasound Guided Nerve Blocks in the ED
    2026/09/10
    Ultrasound-guided nerve blocks are no longer just a niche skill for fellowship-trained ultrasound specialists—they are a core component of modern multimodal pain management in the ED. Endorsed by ACEP, nerve blocks can offer rapid, targeted pain relief without relying solely on systemic opioids, making everything from rest to imaging and procedural workups significantly more comfortable for patients. Today, Dr. Carlos Mikell, UC Davis Emergency Ultrasound Faculty and nerve block expert, joins us to share why every emergency physician should adopt nerve blocks as part of their practice. We’ll break down the top ED blocks, explore innovative indications like genicular nerve blocks for knee pain, and discuss essential safety protocols and how to get started – or become more comfortable – with blocks in your ED. Why Nerve Blocks Belongs in the ED Targeted Relief: Delivers effective, localized pain management as part of a multi-modal pain control approach, sparing patients some of the systemic side effects of opioids.Facilitates ED Workup: Relieves movement-related pain, making imaging, patient transport, and local procedures far easier and more comfortable for the patient.ACEP Endorsement: ACEP’s policy statement formalizes ultrasound-guided nerve blocks as an essential skill for all emergency physicians—not just ultrasound fellowship graduates.Analgesia, Not Complete Anesthesia: The goal in the ED is regional analgesia (taking pain down to a manageable, functional level safely) rather than dense, surgical anesthesia. The Most Common ED Nerve Blocks According to data from the National Ultrasound Guided Nerve Block Registry: Fascia Iliaca Plane / Femoral Nerve Block (~36%): Indications: Hip fractures, mid-shaft/distal femur fractures, hip dislocations, and severe thigh trauma.Safety Profile: Highly safe; target plane is centimeters away from the main neurovascular bundle in a easily compressible site. Erector Spinae Plane (ESP) Block: Indications: Back pain, renal colic, shingles, and rib fractures. Forearm Blocks (Median, Ulnar, Radial): Indications: Distal forearm fractures, complex lacerations, and hand procedures. Serratus Anterior Plane (SAP) Block (~7%): Indications: Rib fractures, pre/post-chest tube insertion pain, and chest wall abscesses.Tip: Hydro-dissect with normal saline first to identify the fascial plane before injecting local anesthetic, and consider adding dexamethasone to extend duration. Innovative Block Spotlight: Genicular Nerve Block Target: Three of the primary sensory branches of the sciatic/femoral nerves supplying the anterior knee.Indications: Acute knee trauma/fractures, acute-on-chronic knee pain, and severe osteoarthritic flare-ups.Safety & Execution: Low-volume block (~10 mL total). Pearl: Omit the inferior-lateral genicular injection to avoid unintentional peroneal nerve block and foot drop. Streamlining Nerve Blocks in Your Department To move nerve blocks from a rare procedure to a routine clinical tool: ED Infrastructure: Build standardized EMR order sets, procedure note templates, and dedicated nerve block supply carts/kits.Departmental Support: Designate a point person to coordinate credentialing, interdisciplinary pathways (e.g., trauma, orthopedics), and physician/nurse/tech education.Hands-on Training: Utilize cadaver labs, simulation, and scanning shifts to build faculty and resident confidence. Non-Negotiable Safety Guidelines & LAST Prevention Nerve blocks are generally low-risk, but vigilance is critical to avoid complications like Local Anesthetic Systemic Toxicity (LAST) or direct nerve injury: Patient Selection: Avoid in uncommunicative patients (who cannot report paresthesias or tinnitus), areas at high risk for compartment syndrome, or pre-existing severe nerve deficits.Monitoring: Keep patients on cardiac telemetry for 30–60 minutes post-block for central or high-volume blocks (>10 mL or above the elbow/knee).Dosing Buffer: Calculate maximum weight-based local anesthetic doses every time; stay within 60–70% of the maximum dose to maintain a safety buffer.Intralipid Availability: Ensure 20% Intralipid is immediately accessible in the ED pharmacy or brought directly to the bedside.Injection Technique: Never point the needle directly at a nerve. Inject into the fascial plane, stop immediately if you encounter resistance, and perform frequent aspirations every 3–5 mL. What is your favorite ultrasound-guided nerve block? What barriers do you encounter to doing blocks in the ED? We’d love to hear form you! Connect with us on social media @empulsepodcast or connect with us on ucdavisem.com Hosts: Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Professor of Pediatric Emergency Medicine at UC Davis Guest: Dr. Carlos Mikell, Assistant Professor of Emergency Medicine and Ultrasound Faculty at UC Davis Resources: ACEP Policy Satement: Ultrasound Guidelines: Emergency, Point-of-care, and Clinical ...
    続きを読む 一部表示
    29 分
  • The Poop Problem: Surviving Cyclospora

    The Poop Problem: Surviving Cyclospora
    2026/08/18
    The Outbreak With over 17,000 cases reported across the U.S., a massive Cyclospora outbreak has taken center stage in public health news, marking it as the third-largest foodborne outbreak in modern American history (behind the 1994 Schwan’s ice cream salmonella outbreak and the 1985 Illinois milk outbreak). Infection causes gastrointestinal symptoms, including diarrhea, bloating, nausea and sometimes vomiting. So, what’s actually driving this surge? Is it safe to eat salad? Pediatric infectious disease expert Dr. Dean Blumberg joins us to break down the science behind the “explosive” symptoms, separate real outbreak epicenters from everyday travel cases, and when to test and treat. Transmission & Geography Mechanism: Cyclospora is a parasite. It is often transmitted via produce contaminated with sewage or irrigation water. Not Person-to-Person: Requires ~1 week in the environment to mature and become infectious. Regional Risk: The epicenter for this outbreak is in the Midwest, related to processed lettuce distribution networks. Outside affected regions, cases remain at expected baseline levels (primarily tied to international travel). Fresh produce consumption remains safe. Pathophysiology & Presentation Cellular Damage: Cyclospora infects and kills small intestine epithelial cells, impairing fluid absorption and causing unabsorbed carbohydrates to ferment into gas. Symptoms: Large-volume, gas-driven “explosive” diarrhea, abdominal bloating, and cramping. Fever is rare; vomiting is variable. Duration: Unlike viral gastroenteritis (1–3 days), untreated Cyclospora can linger for weeks and frequently waxes and wanes. Diagnostic Strategy Routine “O&P x3” tests are obsolete—use multiplex PCR panels (e.g., GI BioFire). When to Test: Symptoms lasting >5–7 days, high-risk patients (infants <12 months, older adults, immunocompromised), fever, bloody stool, or symptoms seriously impacting daily life. (Negative panels can help rule out infectious causes and prompt work up for other etiologies, such as IBD) When to Skip: Patients with 1–2 days of mild symptoms or the “worried well.” Treatment First-Line Agent: Trimethoprim-sulfamethoxazole (TMP-SMX / Bactrim). Indication: Treat anyone who tests positive and remains actively symptomatic to speed recovery and prevent relapses. Reporting: Confirmed cases are automatically reported to public health by the lab. Primary Complication: Severe dehydration and electrolyte derangements (the main drivers of hospitalization). Have you seen many Cyclospora cases? Or an influx of concerned patients with mild GI symptoms? Share your experience with us on social media @empulsepodcast or at ucdavisem.com Hosts: Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis Guests: Dr. Dean Blumberg, Chief of Pediatric Infectious Diseases at UC Davis Resources: CDC: Cyclosporiasis AAP News: CDC offers guidance on cyclosporiasis outbreaks for clinicians, public July 14, 2026 Melissa Jenco, Senior News Editor *** Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.
    続きを読む 一部表示
    14 分
adbl_web_anon_alc_button_suppression_t1
まだレビューはありません