We discuss the impact of family presence during resuscitations.

Hosts:
Ellen Duncan, MD, PhD
Brian Gilberti, MD

• Historical Context: The conversation around allowing family members in the room during resuscitation events began gaining attention in 1987. Since then, the practice has been increasingly encouraged.
• Current Practices in Pediatrics:
  • Family presence during pediatric resuscitations remains inconsistent, with healthcare provider acceptance ranging from 15% to 85%.
  • Many subspecialists and consultants still request that families step out, often due to outdated concerns.
• Common Concerns & Myths:
  • Interference in resuscitation → Studies show minimal disruption.
  • Legal risks → No increased litigation risk has been demonstrated.
  • Family trauma → Research suggests that presence may help with grieving and reduce PTSD symptoms.

New England Journal of Medicine study on Family Presence During Cardiopulmonary Resuscitation (Jabre et al., 2013):

• In a randomized controlled trial of 570 relatives, PTSD-related symptoms were significantly higher in family members who were not offered the oppo...

We discuss the recognition and treatment of necrotizing fasciitis.

Hosts:
Aurnee Rahman, MD
Brian Gilberti, MD

0:00 – Introduction

0:41 – Overview

1:10 – Types of Necrotizing Fasciitis

2:21 – Pathophysiology & Risk Factors

3:16 – Clinical Presentation

4:06 – Diagnosis

5:37 – Treatment

7:09 – Prognosis and Recovery

7:37 – Take Home points

• Necrotizing soft tissue infections can be easily missed in routine cases of soft tissue infection.
• High mortality and morbidity underscore the need for vigilance.

• A rapidly progressive, life-threatening infection of the deep soft tissues.
• Involves fascia and subcutaneous fat, causing fulminant tissue destruction.
• High mortality often due to delayed recognition and treatment.

• Type I (Polymicrobial)
  • Involves aerobic and anaerobic organisms (e.g., Bacteroides, Clostridium, Peptostreptococcus).
  • Common in immunocompromised patients or thos...

We sit down with one of our toxicologists to discuss acetaminophen toxicity.

Hosts:
Marlis Gnirke, MD
Brian Gilberti, MD

0:35 – Hidden acetaminophen toxicity in OTC products

3:24 – Pharmacokinetics and toxicokinetics

6:06 – Clinical Course

9:22 – The antidote – NAC

11:02 – The Rumack-Matthew Nomogram

17:36 – Treatment protocols

22:34 – Monitoring and Lab Work

23:23 – Considerations when treating pediatric patients

23:57 – IV APAP overdose, fomepizole

25:42 – Take Home Points

Acetaminophen vs. Tylenol:

• The importance of recognizing that acetaminophen is found in many products beyond Tylenol.
• Common medications containing acetaminophen, such as Excedrin, Fioricet, Percocet, Dayquil/Nyquil, and others.
• The risk of unintentional overdose due to combination products.

Prevalence of Acetaminophen Toxicity:

We review Sexually Transmitted Infections and pertinent updates in diagnosis and management.

Hosts:
Avir Mitra, MD
Brian Gilberti, MD

(1:49) Chlamydia

(3:31) Gonorrhea

(4:50) PID

(6:14) Syphilis

(8:08) Neurosyphilis

(9:13) Tertiary Syphilis

(10:06) Trichomoniasis

(11:13) Herpes

(12:49) HIV

(14:10) PEP

(15:13) Mycoplasma Genitalium

(18:00) Take Home Points

Chlamydia:

• Prevalence:

• • • Most common STI.
    • High percentage of asymptomatic cases (40% to 96%).

• Presentation:

• • • Urethritis, cervicitis, pelvic inflammatory disease (PID), prostatitis, proctitis, pharyngitis, arthritis.
    • Importance of considering ...

We discuss migraines with one of the authorities in the field.

Hosts:
Benjamin Friedman, MD of Montefiore
Brian Gilberti, MD

Initial Approach to Diagnosing Migraines:

• Differentiating between primary headaches (migraine, tension-type, cluster) and secondary causes (e.g., subarachnoid hemorrhage).
• The importance of patient history and reevaluation after initial treatment.
• Recognizing the unique presentation of cluster headaches and their management implications.

Effective Acute Migraine Treatments:

• First-line treatments including anti-dopaminergic medications like metoclopramide (Reglan) and prochlorperazine (Compazine), and parenteral NSAIDs like ketorolac (Toradol).
• The limited role of triptans in the ED due to side effects and less efficacy compared to anti-dopaminergics.
• The use of nerve blocks (greater occipital nerve block and sphenopalatine ganglion block) as effective treatments without systemic side effects.

Treatments to Avoid or Use with Caution:

• Diphenhydramine (Benadryl): Studies show it does not prevent akathisia from anti-dopaminergics nor improve migraine outcomes.
• IV Fluids: Routine use is not supported unless the patient shows signs of dehydration.
• Magnesium: Conflicting evidence with some studies showing no benefit or even harm.

Managing Refractory Migraines:

• Second-line treatments including additional doses of metoclopramide combined with NSAIDs or dihydroergotamine (DHE).
• Considering opioids as a last resort when other treatments fail.

We discuss a new class of medications, Immune Checkpoint Inhibitors, and their side effects.

Hosts:
Avir Mitra, MD
Brian Gilberti, MD

• ICIs are a relatively new class of oncologic drugs that have revolutionized cancer treatment.
• Unlike chemotherapy, ICIs help the immune system develop memory against cancer cells and adapt as the cancer mutates.
• Since their release in 2011, ICIs have expanded to 83 indications for 17 different cancers, with approximately 230,000 patients using them.

• Cancer cells can evade the immune system by binding to T cell receptors that downregulate the immune response.
• ICIs work by blocking these receptors or ligands, preventing the downregulation and allowing T cells to proliferate and attack cancer cells.
• Common ICIs

• ICIs can lead to autoimmune attacks on healthy cells due to immune system upregulation.

We discuss a case of ataxia in children and how to approach the evaluation of these pts.

Hosts:
Ellen Duncan, MD, PhD
Brian Gilberti, MD

Introduction

• The episode focuses on ataxia in children, which can range from self-limiting to life-threatening conditions.
• Pediatric emergency medicine specialist shares insights on the topic.

The Case

• An 18-month-old boy presented with ataxia, unable to keep his head up, sit, or stand, and began vomiting.
• Previously healthy except for recurrent otitis media and viral-induced wheezing.
• The decision to take the child to the emergency department (ED) was based on acute symptoms.

Differential Diagnosis

• Common causes include acute cerebellar ataxia, drug ingestion, Guillain-Barre syndrome, and basilar migraine.
• Less common causes include cerebellitis, encephalitis, brain tumors, and labyrinthitis.

Importance of History and Physical Examination

• A detailed history and physical exam are essential in diagnosing ataxia.
• Key factors include time course, recent infections, signs of increased intracranial pressure, and toxic exposures.
• Look for signs such as bradycardia, hypertension, vomiting, and overall appearance.

Diagnostic Workup

• Initial tests include point-of-care glucose and neuroimaging for concerns about trauma or increased intracranial pressure.
• MRI is preferred for posterior fossa abnormalities,

We discuss the approach to diagnosing and managing hypernatremia in the emergency department.

Hosts:
Abigail Olinde, MD
Brian Gilberti, MD

Episode Overview:

• Introduction to Hypernatremia
• Definition and basic concepts
• Clinical presentation and risk factors
• Diagnosis and management strategies
• Special considerations and potential complications

Definition and Pathophysiology:

• Hypernatremia is defined as a serum sodium level over 145 mEq/L.
• It can be acute or chronic, with chronic cases being more common.
• Symptoms range from nausea and vomiting to altered mental status and coma.

Causes of Hypernatremia based on urine studies:

• Urine Osmolality > 700 mosmol/kg
  • Causes:
    • Extrarenal Water Losses: Dehydration due to sweating, fever, or respiratory losses
    • Unreplaced GI Losses: Vomiting, diarrhea
    • Unreplaced Insensible Losses: Burns, extensive skin diseases
    • Renal Water Losses with Intact AVP Response:
    • Diuretic phase of acute kidney injury
    • Recovery phase of acute tubular necrosis
    • Postobstructive diuresis
• Urine Osmolality 300-600 mosmol/kg
  • Causes:
    • Osmotic Diuresis: High glucose (diabetes mellitus), mannitol, high urea
    • Partial AVP Deficiency: Incomplete central diabetes insipidus
    • Partial AVP Resistance: Nephrogenic diabetes insipidus
• Urine Osmolality < 300 mosmol/kg
  • Causes:
    • Complete AVP Deficiency: Central diabetes insipidus
    • ...