In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the October 2025 Emergency Medicine Practice article, Emergency Department Evaluation and Management of Patients With Adrenal Insufficiency

Introduction

• Welcome and host introductions
• Brief overview of the episode’s topic
• Resources and CME reminder

Article Overview

• Source: Emergency Medicine Practice, October 2025
• Authors: The Simcoes
• Importance of evidence-based review

Clinical Context & Epidemiology

• Frequency and rarity of adrenal insufficiency
• Diagnostic challenges and statistics
• Importance of recognizing adrenal crisis

Pathophysiology

• Primary, secondary, and tertiary adrenal insufficiency
• Causes and mechanisms
• Key anatomical and physiological concepts

Differential Diagnosis

• Overlap with other diseases (infections, autoimmune, endocrine, psychiatric, cardiac, GI, etc.)
• Importance of considering adrenal crisis in complex cases

Prehospital Care

• EMS recognition and limitations
• Importance of medication history and emergency kits
• Legal and logistical barriers to prehospital hydrocortisone

Emergency Department Evaluation

• Recognizing symptoms and prioritizing care
• Role of EMR and clinical decision support
• Key history and risk factors (medications, steroid use, opioid use, comorbidities)

Physical Examination

• Specific and nonspecific findings
• Cushingoid features vs. primary adrenal insufficiency signs

Diagnostic Workup

• Laboratory studies (cortisol, ACTH, renin, aldosterone, TSH, etc.)
• Imaging considerations
• Gold standard tests and their limitations in the ED

Treatment

• Immediate administration of hydrocortisone
• Dosing for adults and pediatrics
• Supportive care (fluids, glucose, treating underlying cause)
• Sick day dosing and home management

Special Populations

• Pregnancy considerations
• Septic shock and adrenal crisis

Common Pitfalls & Takeaways

• Delaying steroids for labs/diagnosis
• Importance of high suspicion and early treatment
• Key trivia and learning points

ClosingSummary and final thoughts

• Reminders for further reading and CME
• Farewell and next episode teaser

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net

In this episode, Sam Ashoo, MD interviews Evan Dvorin, MD about the dangers of short term steroid use.

Background & Regional Differences

• Dr. Dvorin’s clinical journey from New England to New Orleans.
• Noticing increased use of corticosteroids for common conditions in the Southeast.
• Discussion of how steroid prescribing practices vary by region and setting.

Inappropriate Steroid Use

• Common conditions where steroids are often inappropriately prescribed (sinus infections, bronchitis, sciatica, rashes, plantar fasciitis, etc.).
• Trends showing increased steroid prescribing over time.
• Similar patterns observed in emergency, urgent care, and primary care settings.

Risks and Side Effects of Short-Term Steroid Use

• Short-term steroids can cause significant side effects: infection, sepsis, bone fractures, thromboembolism, psychiatric effects, hyperglycemia.
• Dose-response relationship: higher doses and repeated use increase risks.
• Some side effects (e.g., bone loss) may persist beyond two months.

Patient Communication & Shared Decision-Making

• Importance of discussing risks with patients, tailored to individual risk factors (e.g., diabetes, psychiatric history, age).
• Strategies for educating patients and managing expectations.
• The role of patient education videos and resources.

Impact of Provider Education & Quality Metrics

• Ochsner Health’s initiatives to reduce inappropriate steroid use.
• Use of CME, quality dashboards, and feedback to clinicians.
• Evidence that education and reporting can reduce unnecessary prescriptions.

Special Populations & Scenarios

• Considerations for pediatric patients and repeated dosing.
• Challenges when specialists recommend steroids for certain conditions (e.g., sciatica, neurosurgery cases).
• The need for evidence-based practice and inter-provider communication.

Medical-Legal Considerations

• Lawsuits related to steroid side effects (e.g., fat atrophy, infection).
• Importance of documentation and informed consent.

Alternatives & Symptom Management

• Focusing on treating the patient’s most bothersome symptoms.
• Non-steroid options and the value of patient education about illness duration and expectations.

Resources

• Mention of Dr. Dvorin’s educational video on corticosteroid side effects (available on YouTube).
• Reminder of EB Medicine’s journals and resources for further learning.

Conclusion

• Key takeaway: “Do no harm” and practice evidence-based medicine.
• Encouragement for clinicians to review their prescribing habits and educate patients.

Ochsner "Side effects from corticosteroids" Video: https://www.youtube.com/watch?v=PdMJ9HYxkck

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the September 2025 Emergency Medicine Practice article, Emergency Department Management of Patients With Status Epilepticus

Topic Introduction

• Focus: Status Epilepticus in Adults
• Reference to recent pediatric episode
• Article authors: Dr. Marquez, Dr. Kaur, Dr. Lay

Why Status Epilepticus Matters

• Teaching value and clinical challenge
• Team-based care and multidisciplinary involvement

Guidelines and Evidence

• Review of major guidelines (International League Against Epilepsy, Neurocritical Care Society, American Epilepsy Society)
• Key trials: EcLiPSE, ConSEPT, ESETT
• Updated definition of status epilepticus

Classification and Diagnosis

• Convulsive vs. non-convulsive status
• Importance of repeated neurologic exams
• Diagnostic challenges and mimics (e.g., syncope, psychogenic seizures)

Etiology and Workup

• Acute vs. non-acute causes
• Common triggers: medication noncompliance, metabolic issues, infections, trauma
• Importance of sleep patterns and ammonia levels
• The NORSE acronym (new onset refractory status epilepticus)

Prehospital and ED Management

• Airway, breathing, circulation priorities
• Early pharmacologic intervention (IM midazolam preferred in prehospital)
• Gathering history and medication information
• Positioning and airway protection

Diagnostics

• Laboratory workup: glucose, CBC, metabolic panel, drug levels, pregnancy test
• Imaging: non-contrast CT, MRI, ultrasound, lumbar puncture
• EEG: spot vs. continuous monitoring

Treatment Approach

• First-line: Benzodiazepines (lorazepam, midazolam)
• Second-line: Levetiracetam, valproate, fosphenytoin, phenobarbital, lacosamide
• Third-line: Continuous infusions (midazolam, propofol, pentobarbital, thiopental, ketamine)
• Dosing pearls and importance of rapid escalation

Special Populations

• Pregnancy (eclampsia: magnesium as first-line)
• Substance-induced status epilepticus (e.g., isoniazid toxicity and pyridoxine)
• Brief mention of pediatric management and the PD stat app

Risk Management Pitfalls

• Non-convulsive status is common and easily missed
• Importance of weight-based dosing
• Need for formal EEG in ambiguous cases
• Don’t assume non-adherence is the only cause in known epileptics
• Always consider higher level of care for status patients

Clinical Pathway

• Stepwise approach to medication and escalation
• Emphasis on having a pathway/checklist for these high-stress cases

Conclusion

• Recap of key points
• Thanks to authors and listeners
• Reminder to visit ebmedicine.net for CME and resources

Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net