Core Emergency Medicine

Alcoholic Ketoacidosis

An overview of ketoacidosis, a diagnosis that can be easily missed.

Nephrotic Syndrome

An overview of nephrotic syndrome in the pediatric population.

Core Podcast See More →

Episode 169.0 – Febrile Seizures

A look at the most common type of seizures in the young pediatric population.

Episode 168.0 – Lyme Disease

A review for the emergency physician of this common disease that can take many forms.

Core Procedures See More →

Push-Dose Pressors

A brief video reviewing how to prepare and administer push-dose epinephrine and push-dose phenylephrine.

Read more

Digital Nerve Block

This is a brief video detailing how to do regional anesthesia for the fingers.

Read more

Core Blog See More →

Aug092019

There is a man living in New York City who once suffered a traumatic brain injury and is now frequently brought into our ED by EMS with a chief complaint of “seizure.” Often providers order labs, imaging and medications, prescriptions he doesn’t fill and make clinic appointments he never attends. He appears disheveled so many assume he is addicted to alcohol and has seizures due to withdrawal.
Read More

Jun252019

The new 2019 PEM Guide has been released! 183 PEM topics covered concisely in this free, point of care reference.

Download the PDF

Access the Apple Book

“PEM (Pediatric Emergency Medicine) Guides was developed as an online, point of care resource for the residents and medical students who work with us in our pediatric emergency departments.
Read More

Jun132019

Graduation Speech

Lewis R. Goldfrank, MD

(June 12, 2019)

Congratulations on your graduation.  This milestone and the commencement of your increased independence are a tribute to your fine work.  Your future accomplishments will be substantial.

Your team

You as a class will have developed immensely profound bonds.  
Read More

Core Journal Club See More →

: Dexamethasone in Adults with Bacterial Meningitis

Dexamethasone in Adults with Bacterial Meningitis NEJM, 2002

Morbidity and mortality rates are high among adult patients with acute bacterial meningitis especially those with pneumococcal meningitis. Animal studies have shown that bacterial lysis occuring with antibiotic treatment leads to inflammation in the subarachnoid space and that treatment with dexamethasone,
Read More

: Cervical Spine Injury Risk Factors in Children with Blunt Trauma

Cervical Spine Injury Risk Factors in Children with Blunt Trauma Pediatrics, 2019

Pediatric cervical spine injuries (CSI) are rare (1-2%) after blunt trauma. Decision rules to identify adults at low risk of cervical spine injury have been developed (NEXUS criteria (Hoffman,
Read More

Core Cases More Cases →

CC

Nausea, vomiting, and abdominal pain

HPI

Acid-Base Workshop: At the beginning of the conference year, multiple faculty members ran a workshop on acid-base abnormalities where we worked on identifying acid-base disturbances, determining primary respiratory or metabolic abnormalities, causes of such disturbances, and if compensation was appropriate. Perhaps one of the most challenging types of patients we encounter with an acid-base disturbance is an acidemic patient who we believe requires intubation. Below you will find a variety of resources on acid-base disturbances and more specifically, intubation and ventilation in this patient population. Read the case, consider reviewing the resources below, and think how you would approach this tenuous patient.


The Case:

A 23 yo F with a PMH of poorly controlled T1DM presents to your ED complaining of nausea, vomiting, and abdominal pain. She ran out of her insulin 3 days ago and didn’t have the funds to refill it. Her FS is 415 on POC testing.

Physical Exam

Vitals: 123/80, HR 120s, O2 98%, RR 32, Temp 98.2

General: sleepy but arousable to voice

HEENT: dry mucous membranes

Chest: CTAB, kussmaul breathing

Cardiac: regular rhythm, tachycardic

Abdomen: soft, NTND

Extremities: MAE

Labs

VBG: 7.03/14/65, Calculated Bicarb 5

BMP: 132/4.3/99/3/20/.09>423


What next?

You hang fluids and start an insulin drip, but the patient becomes progressively lethargic and has vomited twice despite anti-emetics. You decide you need to intubate. What next?

Questions

  1. What are the risks of intubating this patient?

  2. What would be your intubation strategy? Method, intubation medications, and things to pay attention to?

  3. Would you consider giving any additional medications (apart from paralytics or sedation medications) prior to intubating? If so, why, and what would be the dosing?

  4. What would be your ventilator settings?

More Info

Basics:

Aliem- Deciphering Acid Base Disorders

Case Content:

Case of the Month, Acidemia

Intubation/Ventilation FOAM:

Critical Care Updates: Resuscitation Sequence Intubation – pH Kills (Part 3 of 3) Podcast 3 – Laryngoscope as a Murder Weapon (LAMW) Series – Ventilatory Kills – Intubating the patient with Severe Metabolic Acidosis Simplifying Mechanical Ventilation – Part 3: Severe Metabolic Acidosis

Peer Reviewed:
Read More