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Hosts, Alex Finch, MD and Venk Bellamkonda, MD explore topics relevant to the practice, education or research of emergency medicine. Enjoy interviews with people on the front lines, thought leaders from around the world, and the comedy and drama of life when it intersects with emergency care. Follow us on X: @AlwaysOnEM Email: AlwaysOnEM@gmail.com
Episodes
6 days ago
6 days ago
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
Monday Apr 01, 2024
Chapter 29 - How to save a life - A primer on ECPR and ED ECMO
Monday Apr 01, 2024
Monday Apr 01, 2024
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.
Thursday Mar 14, 2024
Thursday Mar 14, 2024
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.
Friday Mar 01, 2024
Chapter 28 - Cant stop the bleeding - Mastering epistaxis
Friday Mar 01, 2024
Friday Mar 01, 2024
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
Wednesday Feb 14, 2024
Chapter 27.5 - Unbundling the bundle - Part two of sepsis
Wednesday Feb 14, 2024
Wednesday Feb 14, 2024
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
Thursday Feb 01, 2024
Chapter 27 - Machiavelli's Hectic Fever - Part one of sepsis
Thursday Feb 01, 2024
Thursday Feb 01, 2024
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
Sunday Jan 14, 2024
Grand Rounds - Dr. Dougie Moss - Chart-onomics
Sunday Jan 14, 2024
Sunday Jan 14, 2024
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
Monday Jan 01, 2024
Chapter 26 -Sick young person with spots - Meningococcemia in the ED
Monday Jan 01, 2024
Monday Jan 01, 2024
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
Thursday Dec 14, 2023
Thursday Dec 14, 2023
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
Friday Dec 01, 2023
Chapter 25 - The one where Alex finally gets to ask about REBOA - Hematomas
Friday Dec 01, 2023
Friday Dec 01, 2023
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