by Dr. Anton Helman
Emergency Medicine Cases – Where the Experts Keep You in the Know. For show notes, quizzes, videos and more learning tools please visit emergencymedicinecases.com
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🇺🇲
Publishing Since
3/9/2010
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April 1, 2025
Dr. Lauren Westafer, Dr. Justin Morgenstern, Dr. Bourke Tillman and Anton Helman discuss risk stratification and management strategies for intermediate-risk pulmonary embolism in the emergency department, highlighting critical decision points and lifesaving interventions in this interview
March 11, 2025
Topics in this EM Quick Hits podcast<br /> <a href="https://emergencymedicinecases.com/about/experts-bios/">Stephen Freedman</a> on pediatric bloody diarrhea, S-TEC and hemolytic uremic syndrome (1:06)<br /> <a href="https://emergencymedicinecases.com/about/experts-bios/">Justin Morgenstern</a> on the evidence for IM epinephrine in out of hospital cardiac arrest (27:04)<br /> <a href="https://emergencymedicinecases.com/about/experts-bios/">Matthew McArther</a> on recognition and ED management of dengue fever (33:56)<br /> <a href="https://emergencymedicinecases.com/about/experts-bios/">Andrew Petrosoniak</a> on imaging decision making in trauma in older patients (47:20)<br /> <a href="https://emergencymedicinecases.com/about/experts-bios/" target="_blank" rel="noopener">Brit Long & Michael Gotlieb</a> on recognition and management of TTP (59:10)<br /> <br /> Podcast production, editing and sound design by Anton Helman<br /> Podcast content, written summary & blog post by Brandon Ng, edited by Anton Helman, March, 2025<br /> Cite this podcast as: Helman, A. Freedman, S. Morgenstern, J. McArther, M. Petrosoniak, A. Long, B. Gotlieb, M. EM Quick Hits 63 - S-TEC and HUS, IM Epinephrine in OHCA, Dengue, Geriatric Trauma Imaging, TTP. Emergency Medicine Cases. March, 2025. https://emergencymedicinecases.com/em-quick-hits-march-2025/. Accessed March 11, 2025.<br /> Pediatric bloody diarrhea: Shiga Toxin Producing E. Coli (S-TEC) and HUS<br /> Consider obtaining a stool specimen or rectal swab in the ED for PCR testing (not culture) to detect S-TEC, Salmonella, Shigella, and Campylobacter.<br /> Which children with bloody diarrhea require bloodwork? Most children with blood in stool do not require blood work. Indications for bloodwork include:<br /> <br /> * Hemodynamic instability<br /> * S-TEC is high on your differential (bloodwork may be useful as baseline)<br /> * Recent travel with bloody diarrhea and fever<br /> * Close contact with S-TEC cases (~10% household transmission rate)<br /> <br /> When to suspect S-TEC?<br /> <br /> * Severe crampy abdominal pain<br /> * >15-20 small frequent, mucousy, bloody stools per day<br /> * Low grade fever<br /> * Signs of microangiopathy (e.g. petechiae, jaundice)<br /> * Endemic area<br /> <br /> <br /> <br /> <br /> Children generally do not require stool O&P for acute diarrhea but should be considered for chronic abdominal pain, chronic diarrhea, or failure to thrive.<br /> When to test for C.difficile? There is a high carriage rate of C. diff (up to ~50% in children under 2 years old). Consider C. diff testing only in children with risk factors such as recent antibiotic use or hospitalization, or as a second line test on follow up if bloody diarrhea persists that is not noted to be from another bacterial etiology.<br /> Why is it important to recognize S-TEC?<br /> A complication of S-TEC infection is Hemolytic Uremic Syndrome (HUS), caused by Shiga toxin accumulation in the kidney which leads to the HUS triad: acute kidney injury, hemolysis, and thrombocytopenia.<br /> <br /> * Shiga toxin 2 (STX2) is specifically associated with a 15-20% risk of HUS in children <5 years<br /> <br /> * HUS development increases risk of dialysis to 50-60% within 1 week<br /> * Differentiating between STX1 (<1% risk of HUS) and STX2 toxin can help risk-stratify patients<br /> <br /> <br /> <br /> How to risk stratify a positive STEC result:<br /> <br /> * Assume blood in stool to be STX2 producing STEC until proven otherwise (non-bloody STEC unlikely making Shiga toxin 2 and unlikely to cause HUS)<br /> * Determine duration of diarrhea: HUS develops a median of 7 days after diarrhea onset<br /> <br /> * Diarrhea >10 days = low risk of HUS<br /> <br /> <br /> * Determining if toxin result is STX2+ (high risk)<br /> <br /> How to manage high risk patients with confirmed S-TEC?<br /> <br /> * Manage dehydration aggressively (volume depletion is associated with adverse outcomes in H...
February 18, 2025
Eating disorders have the highest mortality rate of any psychiatric illness, yet they are frequently missed in the Emergency Department as they can be elusive. Only one in 246 patients who screen positive for an eating disorder at triage have a chief complaint suggesting it. These patients don’t always fit the stereotype—many appear “healthy", have normal BMIs, and/or present with vague GI, cardiac, or neurological symptoms. Missing the diagnosis has important consequences. The earlier an eating disorder is identified and the earlier that appropriate treatment is initiated the better the long term outcomes. In this episode, with the expertise of <a href="https://emergencymedicinecases.com/about/experts-bios/">Dr. Samantha Martin</a> and <a href="https://emergencymedicinecases.com/about/experts-bios/">Dr. Jennifer Tomlin</a>, we’ll break down the essential clinical clues, screening questions, red flags, and subtle exam findings that can help Emergency Physicians diagnose eating disorders early and initiate treatment to decrease mortality and long term morbidity in these young patients. Eating disorders need to be thought of as both a psychiatric condition and medical condition to optimize the pick up rate and appropriate management. Missing or mismanaging eating disorders in the ED means missing an opportunity to save a life and prevent long term morbidity...<br /> <br /> Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul<br /> Written Summary and blog post by Anton Helman February, 2025<br /> Cite this podcast as: Helman, A. Tomlin, J. Martin, S. Episode 202 Eating Disorders: Common, Commonly Missed, Mismanaged and Misunderstood. Emergency Medicine Cases. February, 2025. https://emergencymedicinecases.com/eating-disorders. Accessed February 18, 2025<br /> <a class="fusion-button button-flat fusion-button-default-size button-default fusion-button-default button-1 fusion-button-default-span fusion-button-default-type" target="_blank" rel="noopener noreferrer" href="https://emergencymedicinecases.com/resumes-em-cases/">Résumés EM Cases</a>A 16-year-old male presents to the ED with his mother with the chief complaint of intermittent abdominal pain and constipation for several weeks. There are no red flag symptoms for an underlying surgical cause and review of systems is otherwise unremarkable. Vital signs include a HR 50, BP 85/40 T 35.9. Blood work is ordered, and it shows a mildly low potassium at 3.2 mEq/L, a mildly low hemoglobin at 11g/dl and normal liver enzymes. The patient is discharged from the ED with the diagnosis of low-risk nonspecific abdominal pain with a recommendation to follow up with their primary care physician, and instructions to return for list of red flag symptoms. This case represents a miss of a potentially life-threatening diagnosis that Emergency Physicians have little knowledge of.<br /> Eating disorders are common, often elusive, and can be deadly<br /> <br /> * Eating disorders, which include <a href="https://insideoutinstitute.org.au/assets/dsm-5%20criteria.pdf" target="_blank" rel="noopener">anorexia nervosa</a>, <a href="https://insideoutinstitute.org.au/assets/dsm-5%20criteria.pdf" target="_blank" rel="noopener">bulimia nervosa</a>, <a href="https://insideoutinstitute.org.au/assets/dsm-5%20criteria.pdf" target="_blank" rel="noopener">binge eating disorder</a> and <a href="https://insideoutinstitute.org.au/assets/dsm-5%20criteria.pdf" target="_blank" rel="noopener">Avoidant/restrictive food intake disorder (ARFID)</a>, are common with increasing prevalence, increasing visits to emergency departments, and have the highest mortality of any psychiatric illness.<br /> * The lifetime prevalence rates of anorexia nervosa are as high as 4% among females and is increasing among males.<br /> * In young females the mortality rate of eating disorders is estimated to be as high as 10%.<br /> * In a recent study, after a 5-year follow-up the mortality rate of anore...
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