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Our near daily podcasts move quickly to reflect current events, are inspired by real patient care, and speak to the true nature of what it’s like to work in the Emergency Room or Pre-Hospital Setting. Each medical minute is recorded in a real emergency department, by the emergency physician or clinical pharmacist on duty – the ER is our studio and everything is live.
- 1049 - Episode 901: Underdosing in Status Epilepticus
Contributor: Aaron Lessen MD
Educational Pearls:
Lorazepam (Ativan) is dosed at 0.1 mg/kg up to a maximum of 4 mg in status epilepticus
Some ED protocols only give 2 mg initially
The maximum recommended dose of levetiracetam (Keppra) is 60 mg/kg or 4.5 g
In one retrospective study, only 50% of patients received the correct dose of lorazepam
For levetiracetam, it was only 35% of patients
Underdosing leads to complications
Higher rates of intubations
More likely to progress to refractory status epilepticus
References
1. Cetnarowski A, Cunningham B, Mullen C, Fowler M. Evaluation of intravenous lorazepam dosing strategies and the incidence of refractory status epilepticus. Epilepsy Res. 2023;190(November 2022):107067. doi:10.1016/j.eplepsyres.2022.107067
2. Sathe AG, Tillman H, Coles LD, et al. Underdosing of Benzodiazepines in Patients With Status Epilepticus Enrolled in Established Status Epilepticus Treatment Trial. Acad Emerg Med. 2019;26(8):940-943. doi:10.1111/acem.13811
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit
Mon, 29 Apr 2024 - 02min - 1048 - Episode 900: Ketamine Dosing
Contributor: Travis Barlock MD
Educational Pearls:
Ketamine is an NMDA receptor antagonist with a wide variety of uses in the emergency department. To dose ketamine remember the numbers 0.3, 1, and 3.
Pain dose
For acute pain relief administer 0.3 mg/kg of ketamine IV over 10-20 minutes (max of 30 mg).
Note: There is evidence that a lower dose of 0.1-0.15 mg/kg can be just as effective.
Dissociative dose
To use ketamine as an induction agent for intubation or for procedural sedation administer 1 mg/kg IV over 1-2 minutes.
IM for acute agitation
If a patient is out of control and a danger to themselves or others, administer 3 mg/kg intramuscularly (max 500 mg).
If you are giving IM ketamine it has to be in the concentrated 100 mg/ml vial.
Additional pearls
Pushing ketamine too quickly can cause laryngospasm.
Between .3 and 1 mg/kg is known as the recreational dose. You want to avoid this range because this is where ketamine starts to pick up its dissociative effects and can cause unpleasant and intense hallucinations. This is colloquially known as being in the “k-hole”.
References
Gao, M., Rejaei, D., & Liu, H. (2016). Ketamine use in current clinical practice. Acta pharmacologica Sinica, 37(7), 865–872. https://doi.org/10.1038/aps.2016.5
Lin, J., Figuerado, Y., Montgomery, A., Lee, J., Cannis, M., Norton, V. C., Calvo, R., & Sikand, H. (2021). Efficacy of ketamine for initial control of acute agitation in the emergency department: A randomized study. The American journal of emergency medicine, 44, 306–311. https://doi.org/10.1016/j.ajem.2020.04.013
Stirling, J., & McCoy, L. (2010). Quantifying the psychological effects of ketamine: from euphoria to the k-Hole. Substance use & misuse, 45(14), 2428–2443. https://doi.org/10.3109/10826081003793912
Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMS II
Mon, 22 Apr 2024 - 02min - 1047 - Episode 899: Thrombolytic Contraindications
Contributor: Travis Barlock MD
Educational Pearls:
Thrombolytic therapy (tPA or TNK) is often used in the ED for strokes
Use of anticoagulants with INR > 1.7 or PT >15
Warfarin will reliably increase the INR
Current use of Direct thrombin inhibitor or Factor Xa inhibitor
aPTT/PT/INR are insufficient to assess the degree of anticoagulant effect of Factor Xa inhibitors like apixaban (Eliquis) and rivaroxaban (Xarelto)
Intracranial or intraspinal surgery in the last 3 months
Intracranial neoplasms or arteriovenous malformations also increase the risk of bleeding
Current intracranial or subarachnoid hemorrhage
History of intracranial hemorrhage from thrombolytic therapy also contraindicates tPA/TNK
Recent (within 21 days) or active gastrointestinal bleed
Hypertension
BP >185 systolic or >110 diastolic
Administer labetalol before thrombolytics to lower blood pressure
Timing of symptoms
Onset > 4.5 hours contraindicates tPA
Platelet count < 100,000
BGL < 50
Potential alternative explanation for stroke-like symptoms obviating need for thrombolytics
References
1. Fugate JE, Rabinstein AA. Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke. The Neurohospitalist. 2015;5(3):110-121. doi:10.1177/1941874415578532
2. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke a Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Vol 50.; 2019. doi:10.1161/STR.0000000000000211
Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit
Mon, 15 Apr 2024 - 03min - 1046 - Episode 898: Takotsubo Cardiomyopathy
Contributor: Ricky Dhaliwal, MD
Educational Pearls:
Takotsubo cardiomyopathy, also known as "broken heart syndrome,” is a temporary heart condition that can mimic the symptoms of a heart attack, including troponin elevations and mimic STEMI on ECG.
The exact cause is not fully understood, but it is often triggered by severe emotional or physical stress. The stress can lead to a surge of catecholamines which affects the heart (multivessel spasm/paralysed myocardium).
The name "Takotsubo" comes from the Japanese term for a type of octopus trap, as the left ventricle takes on a distinctive shape resembling this trap during systole. The LV is dilated and part of the wall becomes akenetic. These changes can be seen on ultrasound.
The population most at risk for Takotsubo are post-menopausal women.
Coronary angiography is one of the only ways to differentiate Takotsubo from other acute coronary syndromes.
Most people with Takotsubo cardiomyopathy recover fully.
References
Amin, H. Z., Amin, L. Z., & Pradipta, A. (2020). Takotsubo Cardiomyopathy: A Brief Review. Journal of medicine and life, 13(1), 3–7. https://doi.org/10.25122/jml-2018-0067
Bossone, E., Savarese, G., Ferrara, F., Citro, R., Mosca, S., Musella, F., Limongelli, G., Manfredini, R., Cittadini, A., & Perrone Filardi, P. (2013). Takotsubo cardiomyopathy: overview. Heart failure clinics, 9(2), 249–x. https://doi.org/10.1016/j.hfc.2012.12.015
Dawson D. K. (2018). Acute stress-induced (takotsubo) cardiomyopathy. Heart (British Cardiac Society), 104(2), 96–102. https://doi.org/10.1136/heartjnl-2017-311579
Kida, K., Akashi, Y. J., Fazio, G., & Novo, S. (2010). Takotsubo cardiomyopathy. Current pharmaceutical design, 16(26), 2910–2917. https://doi.org/10.2174/138161210793176509
Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII
Wed, 10 Apr 2024 - 03min - 1045 - Episode 897: Adrenal Crisis
Contributor: Ricky Dhaliwal MD
Educational Pearls:
Primary adrenal insufficiency (most common risk factor for adrenal crises)
An autoimmune condition commonly known as Addison's Disease
Defects in the cells of the adrenal glomerulosa and fasciculata result in deficient glucocorticoids and mineralocorticoids
Mineralocorticoid deficiency leads to hyponatremia and hypovolemia
Lack of aldosterone downregulates Endothelial Sodium Channels (ENaCs) at the renal tubules
Water follows sodium and generates a hypovolemic state
Glucocorticoid deficiency contributes further to hypotension and hyponatremia
Decreased vascular responsiveness to angiotensin II
Increased secretion of vasopressin (ADH) from the posterior pituitary
An adrenal crisis is defined as a sudden worsening of adrenal insufficiency
Presents with non-specific symptoms including nausea, vomiting, fatigue, confusion, and fevers
Fevers may be the result of underlying infection
Work-up in the ED includes labs looking for infection and adding cortisol + ACTH levels
Emergent treatment is required
100 mg hydrocortisone bolus followed by 50 mg every 6 hours
Immediate IV fluid repletion with 1L normal saline
The most common cause of an adrenal crisis is an acute infection in patients with baseline adrenal insufficiency
Often due to a gastrointestinal infection
References
1. Bancos I, Hahner S, Tomlinson J, Arlt W. Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol. 2015;3(3):216-226. doi:10.1016/S2213-8587(14)70142-1
2. Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389. doi:10.1210/jc.2015-1710
3. Cronin CC, Callaghan N, Kearney PJ, Murnaghan DJ, Shanahan F. Addison disease in patients treated with glucocorticoid therapy. Arch Intern Med. 1997;157(4):456-458.
4. Feldman RD, Gros R. Vascular effects of aldosterone: sorting out the receptors and the ligands. Clin Exp Pharmacol Physiol. 2013;40(12):916-921. doi:10.1111/1440-1681.12157
5. Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010;162(3):597-602. doi:10.1530/EJE-09-0884
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit
Mon, 01 Apr 2024 - 04min - 1044 - Podcast 896: Cancer-Related Emergencies
Contributor: Travis Barlock, MD
Educational Pearls:
Cancer-related emergencies can be sorted into a few buckets:
Infection
Cancer itself and the treatments (chemotherapy/radiation) can be immunosuppressive. Look out for conditions such as sepsis and neutropenic fever.
Obstruction
Cancer causes a hypercoagulable state. Look out for blood clots which can cause emergencies such as a pulmonary embolism, stroke, superior vena cava (SVC) syndrome, and cardiac tamponade.
Metabolic
Cancer can affect the metabolic system in a variety of ways. For example, certain cancers like bone cancers can stimulate the bones to release large amounts of calcium leading to hypercalcemia. Tumor lysis syndrome is another consideration in which either spontaneously or due to treatment, tumor cells will release large amounts of electrolytes into the bloodstream causing hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.
Medication side effect
Immunomodulators can have strange side effects. A common one to know is Keytruda (pembrolizumab), which can cause inflammation in any organ. So if you have a cancer patient on immunomodulators with any inflammatory changes (cystitis, colitis, pneumonitis, etc), talk to oncology about whether steroids are indicated.
Chemotherapy can cause tumor lysis syndrome (see above), and multiple chemotherapeutics are known to cause heart failure (doxorubicin, trastuzumab), kidney failure (cisplatin), and pulmonary toxicity (bleomycin).
References
Campello, E., Ilich, A., Simioni, P., & Key, N. S. (2019). The relationship between pancreatic cancer and hypercoagulability: a comprehensive review on epidemiological and biological issues. British journal of cancer, 121(5), 359–371. https://doi.org/10.1038/s41416-019-0510-x
Gyamfi, J., Kim, J., & Choi, J. (2022). Cancer as a Metabolic Disorder. International journal of molecular sciences, 23(3), 1155. https://doi.org/10.3390/ijms23031155
Kwok, G., Yau, T. C., Chiu, J. W., Tse, E., & Kwong, Y. L. (2016). Pembrolizumab (Keytruda). Human vaccines & immunotherapeutics, 12(11), 2777–2789. https://doi.org/10.1080/21645515.2016.1199310
Wang, S. J., Dougan, S. K., & Dougan, M. (2023). Immune mechanisms of toxicity from checkpoint inhibitors. Trends in cancer, 9(7), 543–553. https://doi.org/10.1016/j.trecan.2023.04.002
Zimmer, A. J., & Freifeld, A. G. (2019). Optimal Management of Neutropenic Fever in Patients With Cancer. Journal of oncology practice, 15(1), 19–24. https://doi.org/10.1200/JOP.18.00269
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 25 Mar 2024 - 02min - 1043 - Episode 895: Indications for Exogenous Albumin
Contributor: Travis Barlock MD
Educational Pearls:
There are three indications for IV albumin in the ED
Spontaneous bacterial peritonitis (SBP)
Patients with SBP develop renal failure from volume depletion
Albumin repletes volume stores and reduces renal impairment
Albumin binds inflammatory cytokines and expands plasma volume
Reduced all-cause mortality if IV albumin is given with antibiotics
Hepatorenal syndrome
Cirrhosis of the liver causes the release of endogenous vasodilators
The renin-angiotensin-aldosterone system (RAAS) fails systemically but maintains vasoconstriction at the kidneys, leading to decreased renal perfusion
IV albumin expands plasma volume and prevents failure of the RAAS
Large volume paracentesis
Large-volume removal may lead to circulatory dysfunction
IV albumin is associated with a reduced risk of paracentesis-associated circulatory dysfunction
There are many other FDA-approved conditions for which to use exogenous albumin but the data are conflicted about the benefits on mortality
References
1. Arroyo V, Fernandez J. Pathophysiological basis of albumin use in cirrhosis. Ann Hepatol. 2011;10(SUPPL. 1):S6-S14. doi:10.1016/s1665-2681(19)31600-x
2. Bai Z, Wang L, Wang R, et al. Use of human albumin infusion in cirrhotic patients: a systematic review and meta-analysis of randomized controlled trials. Hepatol Int. 2022;16(6):1468-1483. doi:10.1007/s12072-022-10374-z
3. Batool S, Waheed MD, Vuthaluru K, et al. Efficacy of Intravenous Albumin for Spontaneous Bacterial Peritonitis Infection Among Patients With Cirrhosis: A Meta-Analysis of Randomized Control Trials. Cureus. 2022;14(12). doi:10.7759/cureus.33124
4. Kwok CS, Krupa L, Mahtani A, et al. Albumin reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment among patients with cirrhosis and infection: A systematic review and meta-analysis. Biomed Res Int. 2013;2013. doi:10.1155/2013/295153
5. Sort P, Navasa M, Arroyo V, et al. Effect of Intravenous Albumin on Renal Impairment and Mortality in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis. N Engl J Med. 1999;341(6):403-409.
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit
Mon, 18 Mar 2024 - 02min - 1042 - Episode 894: DKA and HHS
Contributor: Ricky Dhaliwal, MD
Educational Pearls:
What are DKA and HHS?
DKA (Diabetic Ketoacidosis) and HHS (Hyperosmolar Hyperglycemic State) are both acute hyperglycemic states.
DKA
More common in type 1 diabetes.
Triggered by decreased circulating insulin.
The body needs energy but cannot use glucose because it can’t get it into the cells.
This leads to increased metabolism of free fatty acids and the increased production of ketones.
The buildup of ketones causes acidosis.
The kidneys attempt to compensate for the acidosis by increasing diuresis.
These patients present as dry and altered, with sweet-smelling breath and Kussmaul (fast and deep) respirations.
HSS
More common in type 2 diabetes.
In this condition there is still enough circulating insulin to avoid the breakdown of fats for energy but not enough insulin to prevent hyperglycemia.
Serum glucose levels are very high – around 600 to 1200 mg/dl.
Also presents similarly to DKA with the patient being dry and altered.
Important labs to monitor
Serum glucose
Potassium
Phosphorus
Magnesium
Anion gap (Na - Cl - HCO3)
Renal function (Creatinine and BUN)
ABG/VBG for pH
Urinalysis and urine ketones by dipstick
Treatment
Identify the cause, i.e. Has the patient stopped taking their insulin?
Aggressive hydration with isotonic fluids.
Normal Saline (NS) vs Lactated Ringers (LR)?
LR might resolve the DKA/HHS faster with less risk of hypernatremia.
Should you bolus with insulin?
No, just start a drip.
0.1-0.14 units per kg of insulin.
Make sure you have your potassium back before starting insulin as the insulin can shift the potassium into the cells and lead to dangerous hypokalemia.
Should you treat hyponatremia?
Make sure to correct for hyperglycemia before treating. This artificially depresses the sodium.
Should you give bicarb?
Replace if the pH < 6.9. Otherwise, it won’t do anything to help.
Don’t intubate, if the patient is breathing fast it is because they are compensating for their acidosis.
References
Andrade-Castellanos, C. A., Colunga-Lozano, L. E., Delgado-Figueroa, N., & Gonzalez-Padilla, D. A. (2016). Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. The Cochrane database of systematic reviews, 2016(1), CD011281. https://doi.org/10.1002/14651858.CD011281.pub2
Chaithongdi, N., Subauste, J. S., Koch, C. A., & Geraci, S. A. (2011). Diagnosis and management of hyperglycemic emergencies. Hormones (Athens, Greece), 10(4), 250–260. https://doi.org/10.14310/horm.2002.1316
Dhatariya, K. K., Glaser, N. S., Codner, E., & Umpierrez, G. E. (2020). Diabetic ketoacidosis. Nature reviews. Disease primers, 6(1), 40. https://doi.org/10.1038/s41572-020-0165-1
Duhon, B., Attridge, R. L., Franco-Martinez, A. C., Maxwell, P. R., & Hughes, D. W. (2013). Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. The Annals of pharmacotherapy, 47(7-8), 970–975. https://doi.org/10.1345/aph.1S014
Modi, A., Agrawal, A., & Morgan, F. (2017). Euglycemic Diabetic Ketoacidosis: A Review. Current diabetes reviews, 13(3), 315–321. https://doi.org/10.2174/1573399812666160421121307
Self, W. H., Evans, C. S., Jenkins, C. A., Brown, R. M., Casey, J. D., Collins, S. P., Coston, T. D., Felbinger, M., Flemmons, L. N., Hellervik, S. M., Lindsell, C. J., Liu, D., McCoin, N. S., Niswender, K. D., Slovis, C. M., Stollings, J. L., Wang, L., Rice, T. W., Semler, M. W., & Pragmatic Critical Care Research Group (2020). Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA network open, 3(11), e2024596. https://doi.org/10.1001/jamanetworkopen.2020.24596
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 11 Mar 2024 - 07min - 1041 - Episode 893: Home Treatments for Button Battery Ingestion
Contributor: Aaron Lessen MD
Educational Pearls:
Button batteries cause alkaline corrosion and erosion of the esophagus when swallowed
Children swallow button batteries, which create a medical emergency as they can perforate the esophagus
A recent study compared various home remedies as first-aid therapy for button battery ingestion
Honey, jam, normal saline, Coca-Cola, orange juice, milk, and yogurt
The study used a porcine esophageal model to assess resistance to alkalinization with the different home remedies
Honey and jam demonstrated a significantly lower esophageal tissue pH compared with normal saline
Histologic changes in the tissue samples appeared 60 minutes later with honey and jam compared with normal saline
These treatments do not preclude medical intervention and battery removal
References
1. Chiew AL, Lin CS, Nguyen DT, Sinclair FAW, Chan BS, Solinas A. Home Therapies to Neutralize Button Battery Injury in a Porcine Esophageal Model. Ann Emerg Med. 2023:1-9. doi:10.1016/j.annemergmed.2023.08.018
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit
Mon, 04 Mar 2024 - 02min - 1040 - Episode 892: Tourniquets
Contributor: Ricky Dhaliwal, MD
Educational Pearls:
What can you do to control bleeding in a penetrating wound?
Apply direct pinpoint pressure on the wound as well as proximal to the wound.
Build a compression dressing.
How do you build a compression dressing?
Think about building an upside-down pyramid with the gauze.
Consider coagulation agents such as an absorbent gelatin sponge material, microporous polysaccharide hemispheres, oxidized cellulose, fibrin sealants, topical thrombin, or tranexamic acid.
What are the indications to use a tourniquet?
The Stop The Bleed campaign recommends looking for the following features of “life-threatening” bleeding.
Pulsatile bleeding.
Blood is pooling on the ground.
The overlying clothes are soaked.
Bandages are ineffective.
Partial or full amputation.
And if the patient is in shock.
How do you put on a tourniquet?
If using a Combat Application Tourniquet (C-A-T) tourniquet, apply it proximal to the wound, then rotate the plastic rod until the bleeding stops. Then secure the plastic rod with a clip and make sure the Velcro is in place.
Mark the time - generally, there is a spot on the tourniquet to write.
Have a plan for the next steps. Does the patient need emergent surgery? Do they need to be transfered?
How long can you leave a tourniquet on?
Less than 90 minutes.
What are the risks?
Nerve injury.
Ischemia.
References
Latina R, Iacorossi L, Fauci AJ, Biffi A, Castellini G, Coclite D, D'Angelo D, Gianola S, Mari V, Napoletano A, Porcu G, Ruggeri M, Iannone P, Chiara O, On Behalf Of Inih-Major Trauma. Effectiveness of Pre-Hospital Tourniquet in Emergency Patients with Major Trauma and Uncontrolled Haemorrhage: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2021 Dec 6;18(23):12861. doi: 10.3390/ijerph182312861. PMID: 34886586; PMCID: PMC8657739.
Martinson J, Park H, Butler FK Jr, Hammesfahr R, DuBose JJ, Scalea TM. Tourniquets USA: A Review of the Current Literature for Commercially Available Alternative Tourniquets for Use in the Prehospital Civilian Environment. J Spec Oper Med. 2020 Summer;20(2):116-122. doi: 10.55460/CT9D-TMZE. PMID: 32573747.
Resources poster booklet. (n.d.). Stop the Bleed. https://www.stopthebleed.org/resources-poster-booklet/
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
Tue, 27 Feb 2024 - 05min - 1039 - Pharmacy Phriday #11: Riddles, Medical Jargon, NNT, and Time Travel
Contributors: Kali Olson PharmD, Travis Barlock MD, Jeffrey Olson MS2
Summary:
In this episode of Pharmacy Phriday, Dr. Kali Olson joins Dr. Travis Barlock and Jeffrey Olson in studio to discuss a variety of interesting topics in the form of a segment show. Dr. Kali Olson earned her Doctorate of Pharmacy from the University of Colorado, Skaggs School of Pharmacy and completed a PGY1 residency at Detroit Receiving Hospital and a PGY2 residency in Emergency Medicine at Denver Health. She now works as an Emergency Medicine Pharmacist at Denver Health.
In segment one of the show, Kali and Travis answer the Get-To-Know-You questionnaire. In segment two, they work together to answer a series of pharmacy-based riddles. In segment three they play a “Balderdash” like game in which they guess the definitions of medical jargon. In segment four they play the Number Needed to Treat game, invented by the AFP podcast. And in segment five they work together to answer a question about a far-out scenario involving medications and time travel!
References
· American Family Physician Podcast, https://www.aafp.org/pubs/afp/multimedia/podcast.html
· Gragnolati, A. (2022, May 5). The Yuzpe method of emergency contraception. GoodRx. https://www.goodrx.com/conditions/emergency-contraceptive/yuzpe-method
· Manikandan S, Vani NI. Holiday reading: Learning medicine through riddles. CMAJ. 2010 Dec 14;182(18):E863-4. doi: 10.1503/cmaj.100466. PMID: 21149530; PMCID: PMC3001539.
· Riddle Me This: Mixing Medicine, https://peimpact.com/riddle-me-this-mixing-medicine/
· https://thennt.com/nnt/corticosteroids-treatment-kawasaki-disease-children/
· https://thennt.com/nnt/aspirin-acute-ischemic-stroke/
· https://thennt.com/nnt/tranexamic-acid-treatment-epistaxis/
· https://thennt.com/nnt/antibiotics-culture%e2%80%90positive-asymptomatic-bacteriuria-pregnant-women/
Produced, Hosted, Edited, and Summarized by Jeffrey Olson MS2 | Additional editing by Jorge Chalit, OMSII
Fri, 23 Feb 2024 - 43min - 1038 - Episode 891: Hypothermia
Contributor: Taylor Lynch MD
Educational Pearls
Hypothermia is defined as a core body temperature less than 35 degrees Celsius or less than 95 degrees Fahrenheit
Mild Hypothermia: 32-35 degrees Celsius
Presentation: alert, shivering, tachycardic, and cold diuresis
Management: Passive rewarming i.e. remove wet clothing and cover the patient with blankets or other insulation
Moderate Hypothermia: 28-32 degrees Celsius
Presentation: Drowsiness, lack of shivering, bradycardia, hypotension
Management: Active external rewarming
Severe Hypothermia: 24-28 degrees Celsius
Presentation: Heart block, cardiogenic shock, no shivering
Management: Active external and internal rewarming
Less than 24 degrees Celsius
Presentation: Pulseless, ventricular arrhythmia
Active External Rewarming
Warm fluids are insufficient for warming due to a minimal temperature difference (warmed fluids are maintained at 40 degrees vs. a patient at 30 degrees is not a large enough thermodynamic difference)
External: Bear hugger, warm blankets
Active Internal Rewarming
Thoracic lavage (preferably on the patient’s right side)
Place 2 chest tubes (anteriorly and posteriorly); infuse warm IVF anteriorly and hook up the posterior tube to a Pleur-evac
Warms the patient 3-6 Celsius per hour
Bladder lavage
Continuous bladder irrigation with 3-way foley or 300 cc warm fluid
Less effective than thoracic lavage due to less surface area
Pulseless patients
ACLS does not work until patients are rewarmed to 30 degrees
High-quality CPR until 30 degrees (longest CPR in a hypothermic patient was 6 hours and 30 minutes)
Give epinephrine once you reach 35 degrees, spaced out every 6 minutes
ECMO is the best way to warm these patients up (10 degrees per hour)
Pronouncing death must occur at 32 degrees or must have potassium > 12
References
1. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 1: Introduction. Circulation. 2005;112(24 SUPPL.). doi:10.1161/CIRCULATIONAHA.105.166550
2. Brown DJA, Burgger H, Boyd J, Paal P. Accidental Hypothermia. N Engl J Med. 2012;367:1930-1938. doi:10.1136/bmj.2.5543.51-c
3. Dow J, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Wilderness Environ Med. 2019;30(4S):S47-S69. doi:10.1016/j.wem.2019.10.002
4. Kjærgaard B, Bach P. Warming of patients with accidental hypothermia using warm water pleural lavage. Resuscitation. 2006;68(2):203-207. doi:10.1016/j.resuscitation.2005.06.019
5. Lott C, Truhlář A, Alfonzo A, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021;161:152-219. doi:10.1016/j.resuscitation.2021.02.011
6. Plaisier BR. Thoracic lavage in accidental hypothermia with cardiac arrest - Report of a case and review of the literature. Resuscitation. 2005;66(1):99-104. doi:10.1016/j.resuscitation.2004.12.024
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 19 Feb 2024 - 04min - 1037 - Podcast 890: Outdoor Cold Air for Croup
Contributor: Jared Scott MD
Educational Pearls:
Croup is a respiratory condition typically caused by a viral infection (e.g., parainfluenza). The disease is characterized by inflammation of the larynx and trachea, which often leads to a distinctive barking cough.
A common treatment for croup is the powerful steroid dexamethasone, but it can take up to 30 minutes to start working.
A folk remedy for croup is to take the afflicted child outside in the cold to help them breathe better, but does it really work?
A 2023 study in Switzerland, published in the Journal of Pediatrics, investigated whether a 30-minute exposure to outdoor cold air could improve mild to moderate croup symptoms before the onset of steroid effects.
The randomized controlled trial included children aged 3 months to 10 years with croup.
After receiving a single-dose oral dexamethasone, participants were exposed to either outdoor cold air or indoor room air. The primary outcome was a decrease in the Westley Croup Score (WCS) by at least 2 points at 30 minutes.
The results indicated that exposure to outdoor cold air, in addition to dexamethasone, significantly reduced symptoms in children with croup, especially in those with moderate cases.
References
Siebert JN, Salomon C, Taddeo I, Gervaix A, Combescure C, Lacroix L. Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics. 2023 Sep 1;152(3):e2023061365. doi: 10.1542/peds.2023-061365. PMID: 37525974.
Summarized by Jeffrey Olson, MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
Wed, 14 Feb 2024 - 04min - 1036 - Podcast 889: Blood Pressure Cuff Size
Contributor: Aaron Lessen MD
Educational Pearls:
Does the size of a blood pressure (BP) cuff matter?
A recent randomized crossover trial revealed that, indeed, cuff size can affect blood pressure readings
Design
195 adults with varying mid-upper arm circumferences were randomized to the order of BP cuff application:
Appropriate
Too small
Too large
Individuals had their mid-upper arm circumference measured to determine the appropriate cuff size
Participants underwent 4 sets of triplicate blood pressure measurements, the last of which was always with the appropriately sized cuff
Results
In individuals requiring a small cuff, the use of a regular cuff resulted in blood pressure readings 3.6 mm Hg lower than with the small cuff
In individuals requiring large cuffs, the use of a regular cuff resulted in pressures 4.8 mm Hg higher than with the large cuffs
In individuals requiring extra-large cuffs, the use of a regular cuff resulted in pressures 19.5 mm Hg higher than with extra-large cuffs
Conclusion
Miscuffing results in significantly inaccurate blood pressure measurements
It is important to emphasize individualized BP cuff selection
References
1. Ishigami J, Charleston J, Miller ER, Matsushita K, Appel LJ, Brady TM. Effects of Cuff Size on the Accuracy of Blood Pressure Readings: The Cuff(SZ) Randomized Crossover Trial. JAMA Intern Med. 2023;183(10):1061-1068. doi:10.1001/jamainternmed.2023.3264
Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit
Mon, 05 Feb 2024 - 01min - 1035 - Podcast 888: Low GCS and Intubation
Contributor: Aaron Lessen MD
Educational Pearls:
Is the adage, “GCS of 8, you’ve got to intubate” accurate? A recent study published in the November 2023 issue of JAMA attempted to answer this question.
Design
Multicenter, randomized trial, in France from 2021 to 2023.
225 patients experiencing comatose in the setting of acute poisoning were randomly assigned to either a conservative airway strategy of withholding intubation or “routine practice” of much more frequent intubation.
The primary outcome was a composite endpoint including in-hospital death, length of intensive care unit stay, and length of hospital stay.
Secondary outcomes included adverse events from intubation and pneumonia within 48 hours.
Results
Results showed that in the intervention group (with intubation withholding), only 16% of patients were intubated, compared to 58% in the control group.
No in-hospital deaths occurred in either group.
The intervention group demonstrated a significant clinical benefit for the primary endpoint, with a win ratio of 1.85 (95% CI, 1.33 to 2.58).
The conservative airway management strategy also saw a statistically significant decrease in adverse events from intubation and pneumonia.
Conclusion
Among comatose patients with suspected acute poisoning, a conservative strategy of withholding intubation was associated with a greater clinical benefit.
This suggests that a judicious approach to intubation is appropriate in many other settings and clinicians should rely on more than the GCS to make this decision.
References
Freund Y, Viglino D, Cachanado M, Cassard C, Montassier E, Douay B, Guenezan J, Le Borgne P, Yordanov Y, Severin A, Roussel M, Daniel M, Marteau A, Peschanski N, Teissandier D, Macrez R, Morere J, Chouihed T, Roux D, Adnet F, Bloom B, Chauvin A, Simon T. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023 Dec 19;330(23):2267-2274. doi: 10.1001/jama.2023.24391. PMID: 38019968; PMCID: PMC10687712.
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 29 Jan 2024 - 02min - 1034 - Podcast 887: Family Presence in Cardiac Resuscitation
Contributor: Aaron Lessen MD
Educational Pearls:
A 2013 study randomized families of those in cardiac arrest into two groups:
Actively offered patients’ families the opportunity to observe CPR
Follow standard practice regarding family presence (control group)
Of the 266 relatives that received offers to observe CPR, 211 (79%) accepted vs. 43% in the control group observed CPR
The study assessed a primary end-point of PTSD-related symptoms 90 days after the event
Secondary end-points included depression, anxiety, medicolegal claims, medical efforts at resuscitation, and the well-being of the healthcare team
The frequency of PTSD-related symptoms was significantly higher in the control group
Lower rates of anxiety and depression for the families who witnessed CPR
There were no effects on resuscitation efforts, patient survival, medicolegal claims, or stress on the healthcare team
If families choose to witness CPR, it’s beneficial to have someone with the family to explain the process
References
1. Jabre P, Belpomme V, Azoulay E, et al. Family Presence during Cardiopulmonary Resuscitation. N Engl J Med. 2013;368(11):1008-1018. doi:10.1056/NEJMoa1203366
Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit
Mon, 22 Jan 2024 - 02min - 1033 - Podcast 886: Cough in Kids
Contributor: Ricky Dhaliwal, MD
Educational Pearls:
Croup
Caused by:
Parainfluenza, Adenovirus, RSV, Enterovirus (big right now)
Age range:
6 months to 3 years
Symptoms:
Barky cough
Inspiratory stridor (Severe = stidor at rest)
Use the Westley Croup Score to gauge the severity
Treatment:
High flow, humidified, cool oxygen
Dexamethasone 0.6 mg/kg oral, max 16mg
Severe: Racemic Epinephrine 0.5 mL/kg
Consider heliox, a mixture of helium and oxygen
Very severe: be ready to intubate
Bronchiolitis
Caused by:
RSV, Rhinovirus
Symptoms are driven by secretions
Symptoms:
Cough
Wheezing
Dehydration (often the symptom that makes them look the worst)
Age range:
2 to 6 months
Treatment:
Suctioning
Oxygen
IV fluids
Nebulized hypertonic saline
DuoNebs? No.
Asthma
Caused by:
Environmental factors
Viral illness with a predisposition
Treatment:
Beta agonists
Steroids
Ipratropium
Magnesium (relaxes smooth muscle)
References
Dalziel SR, Haskell L, O'Brien S, Borland ML, Plint AC, Babl FE, Oakley E. Bronchiolitis. Lancet. 2022 Jul 30;400(10349):392-406. doi: 10.1016/S0140-6736(22)01016-9. Epub 2022 Jul 1. PMID: 35785792.
Hoch HE, Houin PR, Stillwell PC. Asthma in Children: A Brief Review for Primary Care Providers. Pediatr Ann. 2019 Mar 1;48(3):e103-e109. doi: 10.3928/19382359-20190219-01. PMID: 30874817.
Midulla F, Petrarca L, Frassanito A, Di Mattia G, Zicari AM, Nenna R. Bronchiolitis clinics and medical treatment. Minerva Pediatr. 2018 Dec;70(6):600-611. doi: 10.23736/S0026-4946.18.05334-3. Epub 2018 Oct 18. PMID: 30334624.
Smith DK, McDermott AJ, Sullivan JF. Croup: Diagnosis and Management. Am Fam Physician. 2018 May 1;97(9):575-580. PMID: 29763253.
Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978 May;132(5):484-7. doi: 10.1001/archpedi.1978.02120300044008. PMID: 347921.
https://www.mdcalc.com/calc/677/westley-croup-score
Summarized by Jeffrey Olson | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 15 Jan 2024 - 06min - 1032 - Podcast 885: Penetrating Neck Injuries
Contributor: Ricky Dhaliwal MD
Educational Pearls:
Three zones of the neck with different structures and risks for injuries:
Zone 1 is the most caudal region from the clavicle to the cricoid cartilage
Zone 2 is from the cricoid cartilage to the angle of the mandible
Zone 3 is superior to the angle of the mandible
Zone 1 contains the thoracic outlet vasculature (subclavian arteries and veins, internal jugular veins), carotid arteries, vertebral artery, apices of the lungs, trachea, esophagus, spinal cord, thoracic duct, thyroid gland, jugular veins, and the vagus nerve.
Zone 2 contains the common carotid arteries, internal and external branches of carotid arteries, vertebral arteries, jugular veins, trachea, esophagus, larynx, pharynx, spinal cord, and vagus and recurrent laryngeal nerves
Lower risk than Zone 1 or Zone 3
Zone 3 contains the distal carotid arteries, vertebral arteries, jugular veins, pharynx, spinal cord, cranial nerves IX, X, XI, XII, the sympathetic chain, and the salivary and parotid glands
Hard signs that indicate direct transfer to OR:
Airway compromise
Active, brisk bleeding
Pulsatile hematomas
Hematemesis
Massive subcutaneous emphysema
Soft signs that may obtain imaging to determine further interventions:
Hemoptysis
Oropharyngeal bleeding
Dysphagia
Dysphonia
Expanding hematomas
Soft sign management includes ABCs, type & screen, and airway interventions followed by imaging of the head & neck area
Patients with dysphonia or dysphagia with subsequent negative CTAs may get further work-up via swallow studies
References
Asensio JA, Chahwan S, Forno W, et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma. 2001;50(2):289-296. doi:10.1097/00005373-200102000-00015
Azuaje RE, Jacobson LE, Glover J, et al. Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma. Am Surg. 2003;69(9):804-807.
Ibraheem K, Wong S, Smith A, et al. Computed tomography angiography in the "no-zone" approach era for penetrating neck trauma: A systematic review. J Trauma Acute Care Surg. 2020;89(6):1233-1238. doi:10.1097/TA.0000000000002919
Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: A guide to evaluation and managementx. Ann R Coll Surg Engl. 2018;100(1):6-11. doi:10.1308/rcsann.2017.0191
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Wed, 10 Jan 2024 - 04min - 1031 - Laboring Under Pressure Episode 2: Postpartum Hemorrhage with Dr. Kiersten Williams
Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS2
Summary:
In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss a clip from Dr. Williams’ talk at the “Laboring Under Pressure, Managing Obstetric Emergencies in a Global Setting” event from May 2023. This event was hosted at the University of Denver and was organized with the help of Joe Parker as a fundraiser for the organization Health Outreach Latin America (HOLA).
Dr. Kiersten Williams completed her OBGYN residency at Bay State Medical Center and practices as an Obstetric Hospitalist at Presbyterian/St. Luke’s Medical Center in Denver, Colorado.
During her talk, Dr. Williams walks the audience through the common causes and treatments for post-partum hemorrhage (PPH).
Some important take-away points from this talk are:
The most common causes of PPH can be remembered by the 4 T’s. Tone (atony), Trauma, Tissue (retained placenta), and Thrombin (coagulopathies).
AV malformations of the uterus are probably underdiagnosed.
Quantitative blood loss is much more accurate than estimated blood loss (EBL).
The ideal fibrinogen for an obstetric patient about to deliver is above 400 mg/dl - under 200 is certain to cause bleeding.
Do not deliver oxytocin via IV push dose, it can cause significant hypotension.
Tranexamic Acid is available in both IV and PO and can be administered in the field. The dose is 1 gram and can be run over 10 minutes if administered via IV. It is best if used within 3 hours of delivery.
When performing a uterine massage, place one hand inside the vagina and one hand on the lower abdomen. Then rub the lower abdomen like mad.
A new option for treating PPH is called the JADA System which is slimmer than a Bakri Balloon and uses vacuum suction to help the uterus clamp down.*
Another option for a small uterus is to insert a 60 cc Foley catheter.
In an operating room, a B-Lynch suture can be put in place, uterine artery ligation can be performed, and as a last resort, a hysterectomy can be done.
*EMM is not sponsored by JADA system or the Bakri balloon.
References
Andrikopoulou M, D'Alton ME. Postpartum hemorrhage: early identification challenges. Semin Perinatol. 2019 Feb;43(1):11-17. doi: 10.1053/j.semperi.2018.11.003. Epub 2018 Nov 14. PMID: 30503400.
Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-e186. doi: 10.1097/AOG.0000000000002351. PMID: 28937571.
Federspiel JJ, Eke AC, Eppes CS. Postpartum hemorrhage protocols and benchmarks: improving care through standardization. Am J Obstet Gynecol MFM. 2023 Feb;5(2S):100740. doi: 10.1016/j.ajogmf.2022.100740. Epub 2022 Sep 2. PMID: 36058518; PMCID: PMC9941009.
Health Outreach for Latin America Foundation - HOLA Foundation. (n.d.). http://www.hola-foundation.org/
Kumaraswami S, Butwick A. Latest advances in postpartum hemorrhage management. Best Pract Res Clin Anaesthesiol. 2022 May;36(1):123-134. doi: 10.1016/j.bpa.2022.02.004. Epub 2022 Feb 24. PMID: 35659949.
Pacheco LD, Saade GR, Hankins GDV. Medical management of postpartum hemorrhage: An update. Semin Perinatol. 2019 Feb;43(1):22-26. doi: 10.1053/j.semperi.2018.11.005. Epub 2018 Nov 14. PMID: 30503399.
Produced by Jeffrey Olson, MS2 | Edited by Jeffrey Olson and Jorge Chalit, OMSII
Mon, 08 Jan 2024 - 25min - 1030 - Podcast 884: Nerve Blocks
Contributor: Meghan Hurley MD
Educational Pearls:
What is a nerve block?
A nerve block is the medical procedure of injecting anesthetic into the area around a nerve to block pain signals.
They are typically done with ultrasound guidance.
Are nerve blocks effective?
Most of the information we have about nerve blocks is extrapolated from fascia iliaca blocks. This nerve block targets the fascia iliaca compartment, which contains the femoral, lateral femoral cutaneous, and obturator nerves. These blocks are commonly done for hip fractures to help stabilize the patient while awaiting surgical repair.
The data for these types of injections is strong. They decrease pain, they decrease total morphine equivalents needed while a patient is in the hospital, they help mobilize patients earlier and start physical therapy earlier, and they help patients leave the hospital about a day earlier.
What is an example of an agent that can be used?
Bupivacaine. A long acting amide-type local anesthetic. It works best when paired with epinephrine which causes local vasoconstriction and allows the bupivaciaine to bathe the nerve for longer. It gives 5-15 hours of anesthesia (complete sensation loss), and up to 30 hours of analgesia (pain loss).
What’s an example of another block that can be done?
An Erector Spinae Plane (ESP) block is performed in the paraspinal fascial plane in the back. This can be used for pain around the ribs and before a variety of medical procedures including a Nuss procedure, thoracotomies, percutaneous nephrolithotomies, ventral hernia repairs, and even lumbar fusions.
What is one potential complication of a nerve block?
Local Anesthetic Systemic Toxicity (LAST).
There are three ways this can happen:
1) Using too much total anesthetic (Maximum dose of bupivacaine is 2.5 mg/kg).
2) Too much anesthetic is injected into a confined space which then gets absorbed into the venous system.
3) Injecting directly into the vasculature by mistake.
What are the signs that this complication has occurred?
Perioral tingling
Stupor
Coma
Seizures
What can that cause?
Cardiovascular collapse
How is that treated?
Intralipid AKA Soybean Oil, or “lipid emulsion” should be given as a bolus followed by a drip. These patients need to be admitted.
Bolus 1.5 ml/kg (lean body mass) intravenously over 1 min (max ~100 ml).
Continuous infusion at 0.25 mL/kg/min. Max dosing in the first 30 minutes is around 100 ml/kg.
Fun fact: Patients being treated for LAST with intralipid cannot undergo general anesthesia because the intralipid will impact the anesthesia drugs.
References
Long B, Chavez S, Gottlieb M, Montrief T, Brady WJ. Local anesthetic systemic toxicity: A narrative review for emergency clinicians. Am J Emerg Med. 2022 Sep;59:42-48. doi: 10.1016/j.ajem.2022.06.017. Epub 2022 Jun 13. PMID: 35777259.
Carvalho Júnior LH, Temponi EF, Paganini VO, Costa LP, Soares LF, Gonçalves MB. Reducing the length of hospital stay after total knee arthroplasty: influence of femoral and sciatic nerve block. Rev Assoc Med Bras (1992). 2015 Jan-Feb;61(1):40-3. doi: 10.1590/1806-9282.61.01.040. Epub 2015 Jan 1. PMID: 25909207.
Jain N, Kotulski C, Al-Hilli A, Yeung-Lai-Wah P, Pluta J, Heegeman D. Fascia Iliaca Block in Hip and Femur Fractures to Reduce Opioid Use. J Emerg Med. 2022 Jul;63(1):1-9. doi: 10.1016/j.jemermed.2022.04.018. Epub 2022 Aug 4. PMID: 35933265.
Kot P, Rodriguez P, Granell M, Cano B, Rovira L, Morales J, Broseta A, Andrés J. The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019 Jun;72(3):209-220. doi: 10.4097/kja.d.19.00012. Epub 2019 Mar 19. PMID: 30886130; PMCID: PMC6547235.
Lee SH, Sohn JT. Mechanisms underlying lipid emulsion resuscitation for drug toxicity: a narrative review. Korean J Anesthesiol. 2023 Jun;76(3):171-182. doi: 10.4097/kja.23031. Epub 2023 Jan 26. PMID: 36704816; PMCID: PMC10244607.
Weinberg, Guy. LipidRescue™ Resuscitation. http://www.lipidrescue.org/
Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII
Mon, 01 Jan 2024 - 06min - 1029 - Podcast 883: Migraine Treatment in Cardiovascular Disease
Contributor: Jorge Chalit, OMS II
Educational Pearls:
Migraine pathophysiology
Primarily mediated through the trigeminovascular system
Serotonin, dopamine, and calcitonin gene-related peptide (CGRP)
Trigeminovascular system is linked to the trigeminal nucleus caudalis, which relays pain to the hypothalamus and cerebral cortex
One effective treatment for acute migraines is -triptan medications
5-HT1D/1B agonists such as sumatriptan
Often combined with NSAIDs and dopamine antagonists (as antiemetics) in migraine cocktails
Diphenhydramine (Benadryl) was shown to be ineffective in a randomized controlled trial comparing it with placebo and a dopamine antagonist antiemetic.
The -triptan medications carry significant risk for peripheral vasoconstriction and are therefore avoided in cardiovascular disease
One serotonin agonist specifically approved for use in vascular disease
Lasmiditan - 5-HT1F agonist
Slightly different mechanism of action avoids peripheral vasoconstriction
CGRP antagonists are also used in patients who are unresponsive to -triptans
References
1. Friedman WB, Cabral L, Adewunmi V, et al. Diphenhydramine as adjuvant therapy for acute migraine. An ED-based randomized clinical trial. Ann Emerg Med. 2016;67(1):32-39.e3. doi:doi:10.1016/j.annemergmed.2015.07.495
2. Lasmiditan (Reyvow) and ubrogepant (Ubrelvy) for acute treatment of migraine. (2020). The Medical letter on drugs and therapeutics, 62(1593), 35–39.
3. Robbins MS. Diagnosis and Management of Headache: A Review. JAMA - J Am Med Assoc. 2021;325(18):1874-1885. doi:10.1001/jama.2021.1640
4. Vanderpluym JH, Halker Singh RB, Urtecho M, et al. Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis. JAMA - J Am Med Assoc. 2021;325(23):2357-2369. doi:10.1001/jama.2021.7939
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 25 Dec 2023 - 03min - 1028 - Podcast 882: Thrombolytics for Minor Strokes
Contributor: Aaron Lessen MD
Educational Pearls:
How is the severity of a stroke assessed?
Strokes are assessed by the NIH Stroke Scale (NIHSS), this scale has different tasks, such as asking the person to repeat words, move their arms, or follow simple instructions. The maximum score is 42 but any score over 21 is considered severe.
What would qualify as a minor storke?
Wed, 20 Dec 2023 - 02min - 1027 - Podcast 881: Pediatric Readmissions
Contributor: Nick Tsipis MD
Educational Pearls:
The review article assessed 16.3 million patients across six states to identify those at high-risk for critical revisit
Criteria for critical revisit was ICU admission or death within three days of discharge from the ED
Critical revisits are extremely rare
0.1% of patients have a critical revisit after discharge
0.00001% die after revisit
Of the patients that do experience critical revisits, the two major risk factors are
Asthma - relative risk 2.24
Chronic medical conditions - incidence rate ratio 11.03
Of the top ten diagnoses that lead to critical revisits, 5 are respiratory
Others include cellulitis, seizures, gastrointestinal disease, appendectomy, and sickle cell crisis.
References
1. Cavallaro SC, Michelson KA, D’Ambrosi G, Monuteaux MC, Li J. Critical Revisits Among Children After Emergency Department Discharge. Ann Emerg Med. 2023;82(5):575-582. doi:10.1016/j.annemergmed.2023.06.006
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Tue, 12 Dec 2023 - 03min - 1026 - Podcast 880: OB Delivery in the ED
Contributor: Meghan Hurley MD
Educational Pearls:
Pearls about labor:
Labor is split into 3 stages.
Stage 1 starts when the first persistent contractions are felt and goes up until the cervix is fully dilated and the mother starts pushing. Stage 1 is split into two phases: the latent phase (cervix is dilated from 0-4 cm), and the active phase (cervix dilates from 4-10 cm). The latent phase can take between 6 and 12 hours with contractions happening every 5 to 15 minutes. The active phase usually lasts 4-8 hours with contractions occurring as close as every 3 minutes.
Stage 2 is the birth itself, lasting between 20 minutes and 2 hours.
Stage 3 is the delivery of the placenta and typically takes 30 minutes.
37 weeks gestational age is the cutoff for preterm.
Placenta previa: Condition when the placenta overlies the cervix. Classically presents as painless vaginal bleeding in the 3rd trimester. If suspected placenta previa, avoid a speculum exam. Placenta previa can be confirmed on ultrasound.
If the baby is crowning in the ER then the baby should be delivered in the ER. The ideal presentation on crowning is head first (Vertex), specifically ‘left occiput anterior’. In this position, the baby is head first and the head is facing towards the gurney at a slight angle. If the baby is coming out in a breech position then the provider should “elevate the presenting part” by maintaining pressure on the baby as the mother is wheeled to the OR for an emergency C-section.
If a vertex-presenting baby is being delivered vaginally, after the head has been delivered an event called ‘restitution’ must occur to align the baby’s shoulders properly. During this event, the baby goes from facing down towards the gurney to facing sideways.
After restitution, the anterior shoulder should be delivered, followed by the posterior.
After complete delivery, the cord should be clamped (after a 1-3 minute delay), with something sterile.
Gentle downward traction on the cord helps to deliver the placenta. You can place pressure above the pubic bone to prevent the uterus from involuting during this process. This is not the same as a fundal massage which happens after the delivery of the placenta to help the uterus clamp down and prevent postpartum hemorrhage.
References
Hutchison J, Mahdy H, Hutchison J. Stages of Labor. 2023 Jan 30. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 31335010.
Lavery JP. Placenta previa. Clin Obstet Gynecol. 1990 Sep;33(3):414-21. doi: 10.1097/00003081-199009000-00005. PMID: 2225572.
Qian Y, Ying X, Wang P, Lu Z, Hua Y. Early versus delayed umbilical cord clamping on maternal and neonatal outcomes. Arch Gynecol Obstet. 2019 Sep;300(3):531-543. doi: 10.1007/s00404-019-05215-8. Epub 2019 Jun 15. PMID: 31203386; PMCID: PMC6694086.
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 04 Dec 2023 - 08min - 1025 - Podcast 879: A Case of Pediatric Anaphylactic Shock
Contributor: Dr. Taylor Lynch
Educational Pearls:
Time of arrival until intubation was 26 minutes but nobody tried anterior neck access like a cricothyrotomy until his dad arrived
Traditional ACLS protocol is not enough for anaphylactic respiratory arrest
Circulating O2 from compressions alone is not enough to sustain the brain
Patients need a definitive airway and endotracheal tube is the best method
BVM ventilation is not enough to get patients the oxygen they need
Time to anoxic brain injury during a respiratory arrest is 4 minutes
Definition of anaphylactic shock:
Acute laryngeal involvement with bronchospasms after known exposure to an allergen
Do not need to have skin symptoms like the classic wheal and flare
Must also have either hypotension (from vasodilation or end-organ hypoperfusion) or severe GI symptoms (crampy abdominal pain or repetitive vomiting)
Treatment of anaphylactic shock:
Push-dose IV epinephrine is better than IM epinephrine because IM epinephrine takes 4 minutes to circulate and get to the lungs
Ketamine has broncho-dilating properties so it can be used as an induction agent for intubation
Albuterol and ipratropium as continuous bronchodilators
Magnesium and IV steroids
AMAX4 acronym
Adrenaline, Muscle relaxant, Airway, Xtra (bronchodilators, ventilation, vasopressors, and consideration of pneumothorax), 4 minutes to anoxic brain injury
References
Commins SP. Outpatient Emergencies: Anaphylaxis. Med Clin North Am. 2017;101(3):521-536. doi:10.1016/j.mcna.2016.12.003
Ring J, Beyer K, Biedermann T, Bircher A, Duda D FJ et al. Guideline for acute therapy and management of anaphylaxis. S2 guideline of DGAKI, AeDA, GPA, DAAU, BVKJ, ÖGAI, SGAI, DGAI, DGP, DGPM, AGATE and DAAB. Allergo J Int. 2014;23(23):96-112.
McKenzie B. AMAX4: Every Second Counts. Accessed Sunday, November 26, 2023. https://www.amax4.org/
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 27 Nov 2023 - 05min - 1024 - Podcast 878: Opioids for Low Back and Neck Pain
Contributor: Jared Scott MD
Educational Pearls:
Should we use opioids to treat low back and neck pain? The OPAL Trial, published in The Lancet, in June 2023, attempted to answer this very question.
Objective: Investigate the efficacy and safety of a short course of opioid analgesic (oxycodone-naloxone) for acute low back pain and neck pain.
Trial Design: Triple-blinded, placebo-controlled randomized trial, conducted in Emergency and Primary Care in Sydney, Australia, involving adults with 12 weeks or less of low back or neck pain.
Participants: 347 recruited adults (174 in the opioid group, 173 in the placebo group) with at least moderate pain severity.
Intervention: Participants were assigned to receive either an opioid or a placebo for up to 6 weeks.
Primary Outcome: Pain severity at 6 weeks measured with the pain severity subscale of the Brief Pain Inventory (10-point scale).
Results: No significant difference in pain severity at 6 weeks between the opioid group (mean score 2.78) and placebo group (mean score 2.25).
Adverse events were reported by 35% in the opioid group and 30% in the placebo group, with more opioid-related adverse events in the opioid group (e.g., constipation).
Conclusion: Opioids should not be recommended for acute non-specific low back pain or neck pain, as there was no significant difference in pain severity compared with the placebo. The study calls for a change in the frequent use of opioids for these conditions.
Pharmacy Pearl: Why was naloxone mixed with oxycodone?
Naloxone is an opioid receptor antagonist, meaning it can block the effects of opioids. When combined with oxycodone, naloxone's presence discourages certain forms of opioid misuse.
Additionally, naloxone can bind to opioid receptors in the gut and improve symptoms of Opioid Induced Constipation (OIC).
This is the same idea behind Suboxone (buprenorphine/naloxone).
References
Jones CMP, Day RO, Koes BW, Latimer J, Maher CG, McLachlan AJ, Billot L, Shan S, Lin CC; OPAL Investigators Coordinators. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet. 2023 Jul 22;402(10398):304-312. doi: 10.1016/S0140-6736(23)00404-X. Epub 2023 Jun 28. Erratum in: Lancet. 2023 Aug 19;402(10402):612. PMID: 37392748.
Camilleri M, Lembo A, Katzka DA. Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017 Sep;15(9):1338-1349. doi: 10.1016/j.cgh.2017.05.014. Epub 2017 May 19. PMID: 28529168; PMCID: PMC5565678.
Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII
Mon, 20 Nov 2023 - 03min - 1023 - Podcast 877: Viral Respiratory Infections in Children
Contributor: Jared Scott MD
Educational Pearls
A recently published study assessed the burden of respiratory viruses in a longitudinal cohort of children from 0 to 2 years of age
The children in the study received nasal swab PCR testing weekly to determine infectivity
They were also monitored for symptoms via weekly text surveys
The study differentiated between infection and illness by defining an acute respiratory illness (ARI) as fever ≥38°C or cough.
The median infectivity rate was 9.4 viral infections per child per year
The median illness rate was 3.3 ARIs per child per year
The most common etiological viruses isolated from the nasal samples were rhinovirus and enterovirus
Most infections were asymptomatic or mild
References
Teoh, Z., Conrey, S., McNeal, M., Burrell, A., Burke, R. M., Mattison, C., McMorrow, M., Payne, D. C., Morrow, A. L., & Staat, M. A. (2023). Burden of Respiratory Viruses in Children Less Than 2 Years Old in a Community-based Longitudinal US Birth Cohort. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America, 77(6), 901–909. https://doi.org/10.1093/cid/ciad289
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 13 Nov 2023 - 03min - 1022 - Podcast 876: Sedation Pearls
Contributor: Travis Barlock MD
Educational Pearls:
Common sedatives used in the Emergency Department and a few pearls for each.
Propofol
Type: Non-barbiturate sedative hypnotic agonizing GABA receptors.
Benefit: Quick on and quick off (duration of action is approximately 2-7 minutes), helpful for suspected neurologic injury so the patient can wake up and be re-evaluated. Also has the benefit of reducing intracranial pressure (ICP).
Downsides: Hypotension, bradycardia, respiratory depression.
What should you do if a patient is getting hypotensive on propofol?
Do not stop the propofol. Start pressors. May have to reduce the propofol dose if delay in pressors.
Dexmedetomidine (Precedex)
Type: Alpha 2 agonist - causes central sedation
Uses: Patients are more alert and responsive and therefore can be on BiPAP instead of being intubated. Does not cause respiratory depression.
Downsides: Hypotension and Bradycardia.
Caution in using this for head injuries, its side effects can mask the Cushing reflex and make it more difficult to spot acute elevations in ICP and uncal herniation.
Ketamine
Type: NMDA antagonist and dissociative anesthetic, among other mechanisms.
Benefits: Quick Onset (but slower than propofol). Does not cause hypotension, but can even increase HR and BP (Thought to potentially cause hypotension if patient is catecholamine-depleted (ie. sepsis, delayed trauma)).
Dosing ketamine can be challenging. Typically low doses (0.1-0.3mg/kg (max ~30mg)) can give good pain relief. Higher doses (for intubation/procedural sedation) are generally thought to have a higher risk of dissociation.
Downsides: Emergence reactions which include hallucinations, vivid dreams, and agitation. Increased secretions.
Benzos
Type: GABA agonists.
Benefits: Seizure, alcohol withdrawal, agitation due to toxic overdoses.
Push doses are useful because doses can stack. Longer half-life than propofol.
Downsides: Respiratory depression. Longer half-life can make neuro assessments difficult to complete.
Etomidate
MOA: Displaces endogenous GABA inhibitors.
Useful as a one-time dose for quick procedures (cardioversion, intubation). Often drug of choice for intubation since it is thought to have no hemodynamic effects.
Downsides; If used without paralytic - myoclonus. Though to have some adrenal suppression.
Fentanyl
Type: Opioid analgesic. Not traditional sedative.
Benefits: There are many instances in emergency medicine in which sedation can be avoided by prioritizing proper analgesia. Fentanyl can even be used to maintain intubated patients without needing to keep them constantly sedated.
Downsides: Respiratory depression. Patients may have tolerance.
References
Chawla N, Boateng A, Deshpande R. Procedural sedation in the ICU and emergency department. Curr Opin Anaesthesiol. 2017 Aug;30(4):507-512. doi: 10.1097/ACO.0000000000000487. PMID: 28562388.
Keating GM. Dexmedetomidine: A Review of Its Use for Sedation in the Intensive Care Setting. Drugs. 2015 Jul;75(10):1119-30. doi: 10.1007/s40265-015-0419-5. PMID: 26063213.
Lundström S, Twycross R, Mihalyo M, Wilcock A. Propofol. J Pain Symptom Manage. 2010 Sep;40(3):466-70. doi: 10.1016/j.jpainsymman.2010.07.001. PMID: 20816571.
Matchett G, Gasanova I, Riccio CA, Nasir D, Sunna MC, Bravenec BJ, Azizad O, Farrell B, Minhajuddin A, Stewart JW, Liang LW, Moon TS, Fox PE, Ebeling CG, Smith MN, Trousdale D, Ogunnaike BO; EvK Clinical Trial Collaborators. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med. 2022 Jan;48(1):78-91. doi: 10.1007/s00134-021-06577-x. Epub 2021 Dec 14. PMID: 34904190.
Mihaljević S, Pavlović M, Reiner K, Ćaćić M. Therapeutic Mechanisms of Ketamine. Psychiatr Danub. 2020 Autumn-Winter;32(3-4):325-333. doi: 10.24869/psyd.2020.325. PMID: 33370729.
Nakauchi C, Miyata M, Kamino S, Funato Y, Manabe M, Kojima A, Kawai Y, Uchida H, Fujino M, Boda H. Dexmedetomidine versus fentanyl for sedation in extremely preterm infants. Pediatr Int. 2023 Jan-Dec;65(1):e15581. doi: 10.1111/ped.15581. PMID: 37428855.
Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII
Mon, 06 Nov 2023 - 05min - 1021 - Podcast 875: A Pediatric Case of Myopericarditis
Contributor: Meghan Hurley MD
Educational Pearls:
Pericarditis is inflammation of the pericardial sac, which can arise from infectious or non-infectious etiologies
Myocarditis is inflammation of the myocardium, which may accompany pericarditis
Pericarditis clinical findings include:
Diffuse concave ST elevation, classic for acute pericarditis with myocardial involvement. More common in younger male patients
Elevated high-sensitivity troponin - higher levels may occur in young healthy patients
Ultrasound may show pericardial effusions
POCUS may be helpful in assessing left ventricular ejection fraction (LVEF) via E-point septal separation (EPSS)
Elevation in EPSS correlates with decreased LVEF
Treatments:
Anti-inflammatories including NSAIDs and colchicine
Monitor inflammation
Repeat ultrasounds
Risk factors in this patient’s case:
mRNA COVID vaccine - the risk of myocarditis from vaccination is significantly lower than that from COVID-19 infection
Preceding infection
References
1. Gao J, Feng L, Li Y, et al. A Systematic Review and Meta-analysis of the Association Between SARS-CoV-2 Vaccination and Myocarditis or Pericarditis. Am J Prev Med. 2023;64(2):275-284.
2. Imazio M, Gaita F, LeWinter M. Evaluation and treatment of pericarditis: A systematic review. JAMA - J Am Med Assoc. 2015;314(14):1498-1506. doi:10.1001/jama.2015.12763
3. Mckaigney CJ, Krantz MJ, La Rocque CL, Hurst ND, Buchanan MS, Kendall JL. E-point septal separation: A bedside tool for emergency physician assessment of left ventricular ejection fraction. Am J Emerg Med. 2014;32(6):493-497. doi:10.1016/j.ajem.2014.01.045
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 30 Oct 2023 - 06min - 1020 - Episode 874: Bradyarrhythmias
Contributor: Dylan Luyten MD
Educational Pearls:
What is a Bradyarrhythmia?
Also known as a bradyarrhythmia, it is an irregular heart rate that is also slow (below 60 beats per minute).
What can cause it?
Complete heart block AKA third-degree AV block; identified on ECG by a wide QRS, and complete dissociation between the atrial and ventricular rhythms with the ventricular being much slower. Treat with a pacemaker.
Medication overdose, especially beta blockers. Many other drugs can slow the heart as well including: opioids, clonidine, digitalis, amiodarone, diltiazem, and verapamil to name a few.
Electrolyte abnormalities, specifically hyperkalemia. Hypokalemia, hypocalcemia, and hypomagnesemia can also cause bradyarrhythmias.
Myocardial infarction. Either by damaging the AV node or the conduction system itself or by triggering a process called Reperfusion Bradycardia.
Hypothermia. Bradycardia is generally a sign of severe or advanced hypothermia.
References
Jurkovicová O, Cagán S. Reperfúzne arytmie [Reperfusion arrhythmias]. Bratisl Lek Listy. 1998 Mar-Apr;99(3-4):162-71. Slovak. PMID: 9919746.
Simmons T, Blazar E. Synergistic Bradycardia from Beta Blockers, Hyperkalemia, and Renal Failure. J Emerg Med. 2019 Aug;57(2):e41-e44. doi: 10.1016/j.jemermed.2019.03.039. Epub 2019 May 30. PMID: 31155316.
Wung SF. Bradyarrhythmias: Clinical Presentation, Diagnosis, and Management. Crit Care Nurs Clin North Am. 2016 Sep;28(3):297-308. doi: 10.1016/j.cnc.2016.04.003. Epub 2016 Jun 22. PMID: 27484658.
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 23 Oct 2023 - 02min - 1019 - Podcast 873: Intravesical Tranexamic Acid for Gross Hematuria
Contributor: Aaron Lessen MD
Educational Pearls:
Tranexamic acid (TXA) is a common medication to achieve hemostasis in a variety of conditions
Patients visiting the ED for gross hematuria (between March 2022 and September 2022) were treated with intravesical TXA
1 g tranexamic acid in 100 mL NS via Foley catheter
Clamped Foley for 15 minutes
Subsequent continuous bladder irrigation, as is standard in most EDs
Compared with a cohort of patients visiting the ED for a similar concern between March 2021 and September 2021, the TXA patients had:
A shorter median length of stay in the ED (274 min vs. 411 mins, P < 0.001).
A shorter median duration of Foley catheter placement (145 min vs. 308 mins, P < 0.001)
Fewer revisits after ED discharge (2.3% vs. 12.3%, P = 0.031)
References
1. Choi H, Kim DW, Jung E, et al. Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study. Am J Emerg Med. 2023;68:68-72. doi:10.1016/j.ajem.2023.03.020
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 16 Oct 2023 - 02min - 1018 - Podcast 872: Preseptal and Orbital Cellulitis
Contributor: Meghan Hurley MD
Educational Pearls:
What is Cellulitis?
A common and potentially serious bacterial skin infection.
Caused by various types of bacteria, with Streptococcus and Staphylococcus species being the most common.
What is Preseptal Cellulitis and why is it more serious than facial cellulitis?
Preseptal Cellulitis, also known as Periorbital Cellulitis, is a bacterial infection of the soft tissues in the eyelid and the surrounding area.
This requires prompt and aggressive treatment to avoid progression into Orbital Cellulitis.
How is Preseptal Cellulitis treated?
Oral antibiotics for five to seven days.
In the setting of trauma (scratching bug bites) Clindamycin or TMP-SMX (for MRSA coverage) and Amoxicillin-clavulanic acid or Cefpodoxime or Cefdinir.
If there is no trauma, monotherapy with amoxicillin-clavulanic acid is appropriate.
Check immunization status against H.influenzae and adjust appropriately.
What is Orbital Cellulitis, how is it diagnosed, and why is it more serious than Preseptal Cellulitis?
Orbital cellulitis involves the tissues behind the eyeball and within the eye socket itself.
Key features include:
Eye pain.
Proptosis (Bulging of the eye out of its normal position).
Impaired eye movement.
Blurred or double vision.
This can lead to three very serious complications:
Orbital Compartment Syndrome. This can push eye forward, stretch optic nerve, and threaten vision.
Meningitis given that the meninges of the brain are continuous with optic nerve.
Endophthalmitis, which is inflammation of the inner coats of the eye. This can also threaten vision.
If suspected, get a CT of the orbits and/or an MRI to look for an abscess behind the eyes.
How is Orbital Cellulitis treated?
IV antibiotics. Cover for meningitis with Ceftriaxone and Vancomycin.
Add Metronidazole until intracranial involvement has been ruled out.
Drain the abscess surgically. Usually this is performed by an ophthalmologist or an otolaryngologist.
Admit to the hospital.
References
Bae C, Bourget D. Periorbital Cellulitis. 2023 Jul 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261970.
Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Al-Anezi F, Arat YO, Holck DE. Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East. Ophthalmology. 2007 Feb;114(2):345-54. doi: 10.1016/j.ophtha.2006.07.059. PMID: 17270683.
Seltz LB, Smith J, Durairaj VD, Enzenauer R, Todd J. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011 Mar;127(3):e566-72. doi: 10.1542/peds.2010-2117. Epub 2011 Feb 14. PMID: 21321025.
Wong SJ, Levi J. Management of pediatric orbital cellulitis: A systematic review. Int J Pediatr Otorhinolaryngol. 2018 Jul;110:123-129. doi: 10.1016/j.ijporl.2018.05.006. Epub 2018 May 8. PMID: 29859573.
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 09 Oct 2023 - 04min - 1017 - Mental Health Monthly #17: Mania
Contributors:
Andrew White MD - Outpatient Psychiatrist; Fellowship Trained in Addiction Psychiatry; Denver Health
Travis Barlock MD - Emergency Medicine Physician; Swedish Medical Center
Summary
In this episode of Mental Health Monthly, Dr. Travis Barlock hosts Dr. Andrew White to discuss the elements of mania that may be encountered in the emergency department. The discussion includes a helpful mnemonic to assess mania, work-up and treatment in the ED, underlying causes of mania, mental health holds, inpatient treatment, and the role of sleep in mania.
Educational Pearls
Initial assessment of suspected mania can be done via DIGFAST:
Distractibility - Individual that is unable to carry a linear, goal-directed conversation
Impulsivity - Executive functioning is impaired and patients are unable to control their behaviors
Grandiosity - Elevated mood and sense of self to delusions of grandeur
Flight of ideas - Usually described as racing thoughts
Agitation - Increase in psychomotor activity; start several projects of which they have little previous knowledge
Sleep decrease - Typically, manic episodes start with insomnia and can devolve into multiday sleeplessness
Talkativeness - More talkative than usual with pressured speech and a tangential thought process
Interviewing patients requires an understanding of mood-based mania vs. psychosis-based mania
An individual with mood-based mania will more likely be restless, whereas a patient with psychosis-based mania will be more relaxed from a psychomotor standpoint
Treatment of manic patients in the ED includes the use of antipsychotics to manage acute symptomatology
Management can be informed and directed by the patient’s history i.e. known medications that have worked for the patient
ED management of manic patients involves a work-up for a broad differential including agitated delirium, substance-induced mania, metabolic disorders, and autoimmune diseases.
Some individuals experience manic episodes from marijuana and other illicit substances
Antidepressants used in bipolar patients for suspected depression may induce mania
Important to avoid using antidepressants as first-line therapy
Mental health holds can be beneficial in patients with grave disabilities from mania
Oftentimes, undertreatment of manic episodes leads to re-hospitalization
Inpatient treatment:
Environment is important - ensure that patients get solo rooms if possible to minimize stimulation
Antipsychotics, including risperidone and olanzapine, with or without a benzodiazepine, are useful for short-term agitation
Long-term treatment involves coupled pharmacological treatments with non-pharmacological treatments
Sleep
Fractured sleep is one of the earliest warning signs that someone has an imminent manic episode
Poor sleep can be an inciting factor for mania, which then turns into a cycle that further propagates a patient’s manic episode
Summarized and edited by Jorge Chalit, OMSII | Studio production by Jeffrey Olson, MS2
Thu, 05 Oct 2023 - 40min - 1016 - Podcast 871: Increased Intracranial Pressure and the Cushing Reflex
Contributor: Travis Barlock MD
Education Pearls:
The Cushing Reflex is a physiologic response to elevated intracranial pressure (ICP)
Cushing’s Triad: widened pulse pressure (systolic hypertension), bradycardia, and irregular respirations
Increased ICP results from systolic hypertension, which causes a parasympathetic reflex to drop heart rate, leading to Cushing’s Triad.
The Cushing Reflex is a sign of herniation
Treatment includes:
Hypertonic saline is comparable to mannitol and preferable in patients with hypovolemia or hyponatremia
Give 250-500mL of 3%NaCl
20% Mannitol - given at a dose of 0.5-1 g/kg
Each additional dose of 0.1 g/kg reduces ICP by 1 mm Hg
23.4% hypertonic saline is more often given in the neuro ICU
8.4% Sodium bicarbonate lowers ICP for 6 hours without causing metabolic acidosis
Non-pharmacological interventions:
Raise the head of the bed to 30-45 degrees
Remove the c-collar to improve blood flow to the head
Hyperventilation induces hypocapnia, which will vasoconsrict the cerebral arterioles
You hyperventilate on the way to the OR. Otherwise, maintain normocapnia.
References
Alnemari AM, Krafcik BM, Mansour TR, Gaudin D. A Comparison of Pharmacologic Therapeutic Agents Used for the Reduction of Intracranial Pressure After Traumatic Brain Injury. World Neurosurg. 2017;106:509-528. doi:10.1016/j.wneu.2017.07.009
Bourdeaux C, Brown J. Sodium bicarbonate lowers intracranial pressure after traumatic brain injury. Neurocrit Care. 2010;13(1):24-28. doi:10.1007/s12028-010-9368-8
Dinallo S, Waseem M. Cushing Reflex. [Updated 2023 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549801/
Godoy DA, Seifi A, Garza D, Lubillo-Montenegro S, Murillo-Cabezas F. Hyperventilation therapy for control of posttraumatic intracranial hypertension. Front Neurol. 2017;8(JUL):1-13. doi:10.3389/fneur.2017.00250
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 02 Oct 2023 - 03min - 1015 - On The Streets #15: Hydrofluoric Acid Case Review
Contributors:
Kalen Abbott, MD - EM Physician and Medical Director for AirLife Denver
Brendan Reiss - Flight Nurse AirLife Denver
Matt Spoon - Flight Paramedic AirLife Denver
Jordan Ourada - EMS Coordinator at Swedish Medical Center and Paramedic
Summary:
In this episode, hosted by Jordan Ourada, Brendan Reiss and Matt Spoon present a first-hand experience case of hydrofluoric acid exposure in a pediatric patient. Commentary and educational pearls are provided by EM Physician, Kalen Abbott.
The case:
The patient was a male infant who had spilled a large amount of heavy-duty acid aluminum wheel cleaner on himself while playing in his parent's garage. Unclear if he had ingested any fluid. The cleaning fluid contained a large percentage of hydrofluoric acid.
He was brought by EMS to his local hospital, who quickly decided to transport the infant by helicopter to a large Denver hospital.
Initial labs were unremarkable and the EKG was normal. Heart rate was in the 140s. Blood pressure was 110/73. Respirations were around 30 and non-labored. Chest and abdominal x-rays were unremarkable.
The patient had received a water-based decontamination and 1 gram of calcium gluconate IV.
Complications:
Immediately before leaving a nurse informed Brendan and Matt that the serum calcium was 6.8 mg/dl (normal range: 8.5 to 10.2).
During the flight, the patient went into cardiac arrest.
The patient achieved ROSC after CPR was administered in the helicopter.
Once on the ground, an I/O line was started and calcium chloride, sodium bicarb, and normal saline were administered.
Within the first 2 hours that patient received the equivalent of 310 mg/kg of calcium (the pediatric dose is 20 mg/kg)
Care resolution:
The patient ended up having a several-week stay in the pediatric ICU. There were some complications such as pulmonary hemorrhage. Calcium gluconate was continued via nebulization for several days. Ultimately, the child was weaned off the ventilator and spontaneous respirations resumed. They were able to wean the child off vasopressors and sedation over the course of several days. A gastric lavage with calcium gluconate was completed as well during the inpatient stay. The child was able to leave the hospital, neurologically intact after about 14 days.
Pearls:
Lower concentrations of acids can be more dangerous because they don’t immediately burn but rather can be absorbed systemically through the skin.
Calcium is the antidote to hydrofluoric acid exposure.
Calcium chloride has 3 times the elemental calcium as calcium gluconate.
The maximum infusion rate of calcium chloride through a peripheral line is 1 gram every 10 minutes, calcium gluconate can be infused at 1 gram every 5 minutes.
When intubating a patient with acid exposure, avoid succinylcholine because of the risk of hyperkalemia.
References
Caravati EM. Acute hydrofluoric acid exposure. Am J Emerg Med. 1988 Mar;6(2):143-50. doi: 10.1016/0735-6757(88)90053-8. PMID: 3281684.
Pepe J, Colangelo L, Biamonte F, Sonato C, Danese VC, Cecchetti V, Occhiuto M, Piazzolla V, De Martino V, Ferrone F, Minisola S, Cipriani C. Diagnosis and management of hypocalcemia. Endocrine. 2020 Sep;69(3):485-495. doi: 10.1007/s12020-020-02324-2. Epub 2020 May 4. PMID: 32367335.
Strayer RJ. Succinylcholine, rocuronium, and hyperkalemia. Am J Emerg Med. 2016 Aug;34(8):1705-6. doi: 10.1016/j.ajem.2016.05.039. Epub 2016 May 19. PMID: 27241569.
Vallentin MF, Granfeldt A, Meilandt C, Povlsen AL, Sindberg B, Holmberg MJ, Iversen BN, Mærkedahl R, Mortensen LR, Nyboe R, Vandborg MP, Tarpgaard M, Runge C, Christiansen CF, Dissing TH, Terkelsen CJ, Christensen S, Kirkegaard H, Andersen LW. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021 Dec 14;326(22):2268-2276. doi: 10.1001/jama.2021.20929. PMID: 34847226; PMCID: PMC8634154.
Summarized by Jeffrey Olson MS2 | Edited by Jeffrey Olson, Meg Joyce, & Jorge Chalit, OMSII
Fri, 29 Sep 2023 - 41min - 1014 - Episode 870: Advanced Trauma Life Support (ATLS)
Contributor: Meghan Hurley MD
Educational Pearls:
What is ATLS?
Advanced Trauma Life Support (ATLS) is a systematic and comprehensive approach to the evaluation and management of trauma patients
It was developed by the American College of Surgeons (ACS)
The key components include the Primary Survey ("ABCDE"), the Secondary Survey, Definitive Care, and Special Considerations
What are the issues with ATLS?
ATLS relies on many algorithms and rules-of-thumb, which might be helpful for individuals with basic skills and training but might actually present obstacles for those with higher levels of training. Dr. Hurley cites several examples.
Example 1: ABC approach to trauma patients
ABC stands for Airway, Breathing, and Circulation but focusing on the airway first is not always the best decision.
Immediate attention may need to be applied to massive hemorrhage.
Intubating a patient that is hemodynamically unstable may cause cardiac arrest.
A more helpful phrase might be “Resuscitate before you intubate.”
Example 2: C-spine precautions
Cervical collars may impede the likelihood of first-pass success when intubating. The risk of complications from a failed airway may often outweigh the risk of causing a spinal cord injury.
Example 3:Cutting clothes off.
The E of ABCDE stands for exposure which means fully undressing the patient to look for missing injuries. This often involves cutting their clothes off.
This practice might be too broadly applied and leave low-risk trauma patients without any clothes to wear when discharged home.
Example 4: Digital rectal exam
A rectal exam can be a useful tool in the evaluation of patients with abdominal or pelvic injuries. It can help screen for rectal bleeding, pelvic fractures, and neurological function
However, the rectal exam is not a sensitive test. A retrospective study from the Indian Journal of Surgery found that a rectal exam missed 100% of urethra injuries, 92% of spinal cord injuries, 93% of small bowel injuries, 100% of colon injuries, and 67% of rectal injuries in trauma patients.
Example 6: Pushing on pelvis for pelvic injuries
Pushing on the pelvis to check for instability can cause further damage to an unstable pelvis. Imaging the pelvis is far more important than pressing on it if a pelvic fracture is suspected.
Example 7: FAST exam
A FAST exam, which stands for "Focused Assessment with Sonography for Trauma," is a rapid ultrasound examination used to assess trauma patients for signs of internal bleeding or organ damage in the abdomen and chest.
These can be very useful as an initial test to tell a trauma surgeon where to start looking for internal bleeding in an unstable blunt traumatic injury
If a patient is stable and likely going to get a CT scan whether the FAST is positive or negative then the test is unnecessary
References
ATLS Subcommittee; American College of Surgeons’ Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013 May;74(5):1363-6. doi: 10.1097/TA.0b013e31828b82f5. PMID: 23609291.
Bloom BA, Gibbons RC. Focused Assessment With Sonography for Trauma. 2023 Jul 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261902.
Brown R. Oxygenate and Resuscitate Before You Intubate. Common pitfalls to avoid when managing the crashing airway. EMS World. 2016 Jan;45(1):48-50, 52, 54-5. PMID: 26852546.
Chrimes N, Marshall SD. Attempt XYZ: airway management at the opposite end of the alphabet. Anaesthesia. 2018 Dec;73(12):1464-1468. doi: 10.1111/anae.14361. Epub 2018 Jul 11. PMID: 29998563.
Docimo S Jr, Diggs L, Crankshaw L, Lee Y, Vinces F. No Evidence Supporting the Routine Use of Digital Rectal Examinations in Trauma Patients. Indian J Surg. 2015 Aug;77(4):265-9. doi: 10.1007/s12262-015-1283-y. Epub 2015 May 19. PMID: 26702232; PMCID: PMC4688269.
Groeneveld A, McKenzie ML, Williams D. Logrolling: establishing consistent practice. Orthop Nurs. 2001 Mar-Apr;20(2):45-9. doi: 10.1097/00006416-200103000-00011. PMID: 12024634.
Morgenstern, J. The FAST exam: overused and overrated?, First10EM, August 30, 2021.
Rodrigues IFDC. To log-roll or not to log-roll - That is the question! A review of the use of the log-roll for patients with pelvic fractures. Int J Orthop Trauma Nurs. 2017 Nov;27:36-40. doi: 10.1016/j.ijotn.2017.05.001. Epub 2017 May 10. PMID: 28797555.
Sapsford W. Should the 'C' in 'ABCDE' be altered to reflect the trend towards hypotensive resuscitation? Scand J Surg. 2008;97(1):4-11; discussion 12-3. doi: 10.1177/145749690809700102. PMID: 18450202.
Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma. 2014 Mar 15;31(6):531-40. doi: 10.1089/neu.2013.3094. Epub 2013 Nov 6. PMID: 23962031; PMCID: PMC3949434.
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 25 Sep 2023 - 07min - 1013 - Podcast 869: Shift Work
Contributor: Meghan Hurley MD
Educational Pearls:
Shift work is defined as anything that takes place outside of a 9-5 schedule, not exempting day-shift medical workers
Various ill effects of shift work on overall health:
Increased all-cause mortality
Increased number of accidents
Glucose metabolism dysregulation
Increased BMI
Fertility impacts for men and women
Increased breast cancer risk
Decreased cognitive functioning
Mitigation strategies
Work at the same time every day
Anchor Sleep - always try to be asleep at the same time of day
Progressive shifts: day- into swing- into night shift instead of the other way around
Three days off after a stretch of nights can help reset sleep schedule
Shorter night shifts
Morning shifts should start no earlier than 8 AM
Sleep hygiene
Ensure an ideal sleep environment; cool, dark, and damp
Avoid bright lights when going to sleep
Exposure to bright lights when waking up
Hydration throughout your shift
Stop caffeine at midnight if you are working a night shift
Eat healthy meals and avoid junk food
Avoid eating 2-3 hours before going to sleep
References
Boivin, D. B., Boudreau, P., & Kosmadopoulos, A. (2022). Disturbance of the Circadian System in Shift Work and Its Health Impact. Journal of biological rhythms, 37(1), 3–28. https://doi.org/10.1177/07487304211064218
Jang TW. Work-Fitness Evaluation for Shift Work Disorder. Int J Environ Res Public Health. 2021;18(3):1294. Published 2021 Feb 1. doi:10.3390/ijerph18031294
Minors DS, Waterhouse JM. Anchor sleep as a synchronizer of rhythms on abnormal routines. Int J Chronobiol. 1981;7(3):165-188.
Reinganum MI, Thomas J. Shift Work Hazards. [Updated 2023 Jan 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589670/
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 18 Sep 2023 - 04min - 1012 - Episode 868: Airway Management in Obesity
Contributor: Aaron Lessen MD
Educational Pearls:
Why is airway management more difficult in obesity?
Larger body habitus causes the chest to be above the head when the patient is lying supine, creating difficult angles for intubation.
Reduced Functional Residual Capacity (FRC) causes these patients to deoxygenate much more quickly, reducing the amount of time during which the intubation can take place.
What special considerations need to be made?
Positioning. The auditory canal and sternal notch should be aligned in a horizontal plane. Do this by stacking blankets to lift the neck and head. Also, try to make the head itself parallel to the ceiling.
Pre-oxygenation. Use Bi-level Positive Airway Pressure (BiPAP) with Positive End Expiratory Pressure (PEEP) or a Bag-Valve-Mask (BVM) with a PEEP valve. PEEP helps prevent alveoli from collapsing after every breath and improves oxygenation.
Dosing of paralytics. Succinylcholine is dosed on total body weight so the dose will be much larger for the obese patient. Rocuronium is dosed on ideal body weight, but adjusted body weight may also be used in obese cases.
References
De Jong A, Wrigge H, Hedenstierna G, Gattinoni L, Chiumello D, Frat JP, Ball L, Schetz M, Pickkers P, Jaber S. How to ventilate obese patients in the ICU. Intensive Care Med. 2020 Dec;46(12):2423-2435. doi: 10.1007/s00134-020-06286-x. Epub 2020 Oct 23. PMID: 33095284; PMCID: PMC7582031.
Langeron O, Birenbaum A, Le Saché F, Raux M. Airway management in obese patient. Minerva Anestesiol. 2014 Mar;80(3):382-92. Epub 2013 Oct 14. PMID: 24122033.
Sharma S, Arora L. Anesthesia for the Morbidly Obese Patient. Anesthesiol Clin. 2020 Mar;38(1):197-212. doi: 10.1016/j.anclin.2019.10.008. Epub 2020 Jan 2. PMID: 32008653.
Singer BD, Corbridge TC. Basic invasive mechanical ventilation. South Med J. 2009 Dec;102(12):1238-45. doi: 10.1097/SMJ.0b013e3181bfac4f. PMID: 20016432.
Summarized by Jeffrey Olson, MS2 | Edited by Jorge Chalit, OMSII
Mon, 11 Sep 2023 - 03min - 1011 - Episode 867: Occult Scaphoid Fractures
Contributor: Nick Tsipis MD
Educational Pearls:
The scaphoid bone is the most proximal carpal bone just distal to the radius
Fractures of the scaphoid bone are sometimes missed by plain X-rays
A 2020 review found a 21.8% incidence of missed scaphoid fractures later diagnosed by advanced imaging modalities
Only MRI has a sensitivity above 90% for diagnosing scaphoid fractures
Sensitivity of plain-film radiography is low unless it is a displaced fracture
Physical examination techniques fail to definitively rule out scaphoid fractures
A 2023 systematic review assessed the sensitivity and specificity of several common physical exam maneuvers:Tenderness of the anatomical snuffbox has a sensitivity of 92.1% and specificity of 48.4%; i.e. absence reduces the likelihood of an occult scaphoid fracture but does not rule it out
Another common physical exam maneuver is pain with ulnar deviation, which carries a sensitivity of 55.2% and specificity of 76.4%.
Elicitation of pain with supination against resistance demonstrated a sensitivity of 100% and specificity of 97.9% in the study, so the authors recommend externally validating this method
Patients should be counseled on the importance of follow-up given that a fracture may not show up on imaging unless an MRI or repeat XR is done
References
1. Bäcker HC, Wu CH, Strauch RJ. Systematic Review of Diagnosis of Clinically Suspected Scaphoid Fractures. J Wrist Surg. 2020;09(01):081-089. doi:10.1055/s-0039-1693147
2. Coventry L, Oldrini I, Dean B, Novak A, Duckworth A, Metcalfe D. Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies. Emerg Med J. 2023;40(8):576 LP - 582. doi:10.1136/emermed-2023-213119
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 04 Sep 2023 - 04min - 1010 - Podcast 866: Carbamazepine (Tegretol) Overdose
Contributor: Aaron Lessen MD
Educational Pearls:
What is Carbamazepine (Tegretol)?
Carbamazepine is an anti-epileptic drug with mood-stabilizing properties that is used to treat bipolar disorder, epilepsy, and neuropathic pain.
It functions primarily by blocking sodium channels which can prevent repetitive action potential firing.
What are the symptoms of an overdose?
Common initial signs include diminished conscious state, nystagmus, ataxia, hyperreflexia, CNS depression, dystonia, and tachycardia
Severe toxicity can cause seizures, respiratory depression, decreased myocardial contractility, pulmonary edema, hypotension, and dysrhythmias.
How is an overdose treated?
An overdose is treated with large doses of activated charcoal and correction of electrolyte disturbances.
Be ready to intubate given the potential for respiratory depression.
Carbamazepine is moderately dialyzable and dialysis is recommended in severe overdoses.
Additional educational pearl: Individuals in correctional facilities can occasionally self-administer medications which means that medication overdose should still be on the differential for any of these individuals.
References
Epilepsies in children, Young People and adults: NICE guideline [NG217]. National Institute for Health and Care Excellence. (2022, April 27). https://www.nice.org.uk/guidance/ng217
Ghannoum M, Yates C, Galvao TF, Sowinski KM, Vo TH, Coogan A, Gosselin S, Lavergne V, Nolin TD, Hoffman RS; EXTRIP workgroup. Extracorporeal treatment for carbamazepine poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2014 Dec;52(10):993-1004. doi: 10.3109/15563650.2014.973572. Epub 2014 Oct 30. PMID: 25355482; PMCID: PMC4782683.
Seymour JF. Carbamazepine overdose. Features of 33 cases. Drug Saf. 1993 Jan;8(1):81-8. doi: 10.2165/00002018-199308010-00010. PMID: 8471190.
Spiller HA. Management of carbamazepine overdose. Pediatr Emerg Care. 2001 Dec;17(6):452-6. doi: 10.1097/00006565-200112000-00015. PMID: 11753195.
Tran NT, Pralong D, Secrétan AD, Renaud A, Mary G, Nicholas A, Mouton E, Rubio C, Dubost C, Meach F, Bréchet-Bachmann AC, Wolff H. Access to treatment in prison: an inventory of medication preparation and distribution approaches. F1000Res. 2020 May 13;9:357. doi: 10.12688/f1000research.23640.3. PMID: 33123347; PMCID: PMC7570324.
Summarized by Jeffrey Olson, MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 28 Aug 2023 - 02min - 1009 - Laboring Under Pressure- Episode 1. ACLS in Pregnancy with Dr. Jason Papazian
Contributor: Jason Papazian MD, Travis Barlock MD, Jeffrey Olson
Summary:
In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss several clips from Dr. Jason Papazian’s talk at the event “Laboring Under Pressure, Managing Obstetric Emergencies in a Global Setting” from May 2023. This event was hosted at the University of Denver and was organized with the help of Joe Parker as a fundraiser for the organization Health Outreach Latin America (HOLA).
Dr. Jason Papazian practices Obstetric Anesthesiology for the Maternal Fetal Care Unit at Children's Hospital Colorado. He is the Assistant Program Director of Didactics for the Anesthesiology Residency at the University of Colorado, as well as the Faculty Advisor to Residents and Obstetric Anesthesiology Fellows.
During his talk, Dr. Papazian walks the audience through the steps of a maternal cardiac arrest from initial rapid response, to intubation, CPR, ACLS, and eventually emergency cesarean section.
Some important take-away points from this talk are:
The basics save lives. Focus on oxygenating the patient and providing high quality CPR
In order to maximize blood return during CPR on an obstetric patient, manually retract the gravid uterus to the left
If an arresting mother does not obtain return of spontaneous circulation (ROSC) by 4 minutes, the most qualified person should perform a rapid 1-minute bedside cesarean section. This has mortality benefits for both the mother and the infant.
Other medical topics discussed include changes in the obstetric patient’s physiology, roles during a rapid response, steps of intubation, causes of cardiac arrest, management of cardiac arrest, and how pregnancy does (and doesn’t) change ACLS.
References
Bennett TA, Katz VL, Zelop CM. Cardiac Arrest and Resuscitation Unique to Pregnancy. Obstet Gynecol Clin North Am. 2016 Dec;43(4):809-819. doi: 10.1016/j.ogc.2016.07.011. PMID: 27816162.
Campbell TA, Sanson TG. Cardiac arrest and pregnancy. J Emerg Trauma Shock. 2009 Jan;2(1):34-42. doi: 10.4103/0974-2700.43586. PMID: 19561954; PMCID: PMC2700584.
Health Outreach for Latin America Foundation - HOLA Foundation. (n.d.). http://www.hola-foundation.org/
Kikuchi J, Deering S. Cardiac arrest in pregnancy. Semin Perinatol. 2018 Feb;42(1):33-38. doi: 10.1053/j.semperi.2017.11.007. Epub 2017 Dec 13. PMID: 29246735.
Produced by Jeffrey Olson, MS2 | Edited by Jeffrey Olson and Jorge Chalit, OMSII
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Thu, 24 Aug 2023 - 32min - 1008 - Podcast 865: Nausea Treatments - Droperidol vs Ondansetron RCT
Contributor: Aaron Lessen MD
Educational Pearls:
A recent randomized controlled trial compared ondansetron 8 mg IV with droperidol 2.5 mg IV for the treatment of nausea & vomiting in the emergency department.
Overall, droperidol and ondansetron had similar primary outcomes in acute nausea control
Symptom improvement in 93% of patients receiving droperidol vs. 87% receiving ondansetron (P = 0.362)
Secondary measures were, however, statistically significantly different between groups
Patients needed fewer rescue/additional antiemetics in the droperidol group (16%) compared with the ondansetron group (37%); p = 0.016
Similarly, more patients in the droperidol group reported they achieved the desired effect of the medication (85% vs. 63%; p = 0.006)
Patients receiving droperidol did experience increased drowsiness
40% in the droperidol group vs. 11% in the ondansetron group
The trial did not assess the length of stay in the ED after administering medications, which is a potential avenue for future research.
References
1. Philpott L, Clemensen E, Lau GT. Droperidol versus ondansetron for nausea treatment within the emergency department. EMA - Emerg Med Australas. 2023;(December 2022):605-611. doi:10.1111/1742-6723.14174
Summarized & Edited by Jorge Chalit, OMSII
Mon, 21 Aug 2023 - 02min - 1007 - Podcast 864: Arterial Blood Gas (ABG) vs Venous Blood Gas (VBG)
Contributor: Aaron Lessen MD
Educational Pearls:
What is measured in an ABG/VBG?
Blood values for oxygen tension (pO2), carbon dioxide tension (pCO2), acidity (pH), oxyhemoglobin saturation, and bicarbonate (HCO3) in either arterial or venous blood
Other tests can measure methemoglobin, carboxyhemoglobin, hemoglobin levels, base excess, and lactate
What are they used for?
Identification of ventilation/acid-base disturbances. For example: if a patient is in septic shock, oxyhemoglobin saturation can be used to guide resuscitation efforts (early goal- directed therapy)
What's the difference between an ABG and VBG?
One of the main differences is how the blood samples are collected. Venous blood gas is normally collected from existing venous access such as a central venous catheter. Arterial blood gases must be drawn from an artery, such as the radial artery.
Arterial blood draws can be difficult, painful, and contraindicated in many situations.
ABGs have traditionally provided more accurate measurements for assessing oxygenation, ventilation, and acid-base status.
However, several studies have found that VBGs can still be used to accurately assess pH, pCO2, HCO3, lactate, sodium, potassium, chloride, ionized calcium, blood urea nitrogen, base excess, and arterial/alveolar oxygen ratio. This is supported by a recent study in 2023 in the International Journal of Emergency Medicine which specifically studied patients with hypotension and use of VBGs for resuscitation guidance.
Are there other non-invasive methods that can be used to fill in the gaps to avoid ordering an ABG?
Oxygenation can be measured by pulse oximetry
Arterial carbon dioxide tension can be estimated by end-tidal carbon dioxide (PetCO2)
Mixed venous blood gases are another alternative for patients who already have a pulmonary artery catheter
References
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77. doi: 10.1056/NEJMoa010307. PMID: 11794169.
Prasad H, Vempalli N, Agrawal N, Ajun UN, Salam A, Subhra Datta S, Singhal A, Ranjan N, Shabeeba Sherin PP, Sundareshan G. Correlation and agreement between arterial and venous blood gas analysis in patients with hypotension-an emergency department-based cross-sectional study. Int J Emerg Med. 2023 Mar 10;16(1):18. doi: 10.1186/s12245-023-00486-0. PMID: 36899297; PMCID: PMC9999648.
Summarized by Jeffrey Olson, MS2 | Edited by Jorge Chalit, OMSII
Mon, 14 Aug 2023 - 02min - 1006 - Podcast 863: Treatments for Alcohol Use Disorder
Contributor: Aaron Lessen MD
Educational Pearls:
Patients with alcohol use disorder are frequently discharged from the ED without further resources
Pharmacological treatments to reduce cravings in AUD exist
Naltrexone
Effective at reducing alcohol cravings and heavy drinking
Gabapentin
Reduces the percentage of heavy drinking days in AUD
Patients being discharged from the ED should be asked if they feel their alcohol use is a problem, which can further direct appropriate pharmacological interventions
References
1. Kranzler M.D. HR, Feinn Ph.D. R, Morris B.A. P, Hartwell Ph.D. EE. A Meta-analysis of the Efficacy of Gabapentin for Treating Alcohol Use Disorder Henry. Addiction. 2019;114(9):1547-1555. doi:10.1111/add.14655
2. Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: When are these medications most helpful? Addiction. 2013;108(2):275-293. doi:10.1111/j.1360-0443.2012.04054.x
3. Mariani JJ, Pavlicova M, Basaraba C, et al. Pilot randomized placebo-controlled clinical trial of high-dose gabapentin for alcohol use disorder. Alcohol Clin Exp Res. 2021;45(8):1639-1652. doi:10.1111/acer.14648
Summarized & Edited by Jorge Chalit, OMSII
Mon, 07 Aug 2023 - 02min - 1005 - Podcast 862: How to Apply a Painful Stimulus
Contributor: Travis Barlock MD
Educational Pearls:
When might you need to apply a painful stimulus in a medical setting?
The main reason is to assess the patient's level of consciousness, such as when they are waking up from anesthesia or have potentially suffered a brain injury.
It can be part of the Glasgow Coma Scale (GCS) if patients are not responding to auditory stimuli.
Possible levels of consciousness include Alert, Lethargic, Obtunded, and Comatose (ALOC)
What are the approved ways to apply a painful stimulus to assess central nervous system function?
Trapezius squeeze. Grab the trapezius muscle and twist (contraindicated in clavicle fractures).
Supraorbital rim pressure. Find the notch in the supraorbital rim of the patient and push hard with your thumb (contraindicated in facial fractures).
Mandibular pressure (not mentioned). Press hard at the angle of the jaw on the mandibular nerve (contraindicated in mandible fractures).
Sternal rub. Push down with your knuckles into the patient’s sternum and rub vigorously (contraindicated in chest injury/surgery).
Each technique should be done for between 15 and 30 seconds.
If skin damage is observed in one location, move to a different location. This is especially true of the sternal rub.
Important note: Peripheral techniques such as nail tip pressure should only be used to evaluate spinal nerve reflexes and not as a method of assessing the level of consciousness.
References
Lower J. Using pain to assess neurologic response. Nursing. 2003 Jun;33(6):56-7. doi: 10.1097/00152193-200306000-00047. PMID: 12799591.
Middleton PM. Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology. Australas Emerg Nurs J. 2012 Aug;15(3):170-83. doi: 10.1016/j.aenj.2012.06.002. Epub 2012 Aug 3. PMID: 22947690.
Mistovich JJ, Krost W, Limmer DD. Beyond the basics: patient assessment. Emerg Med Serv. 2006 Jul;35(7):72-7; quiz 78-9. PMID: 16878751.
Naalla R, Chitirala P, Chittaluru P, Atreyapurapu V. Sternal rub causing presternal abrasion in a patient with capsuloganglionic haemorrhage. BMJ Case Rep. 2014 Apr 7;2014:bcr2014204028. doi: 10.1136/bcr-2014-204028. PMID: 24711478; PMCID: PMC3987201.
Summarized by Jeffrey Olson, MS2 | Edited by Jorge Chalit, OMSII
Mon, 31 Jul 2023 - 02min - 1004 - Podcast 861: Alcohol Withdrawal and Delirium Tremens
Contributor: Travis Barlock MD
Educational Pearls:
Alcohol binds the GABA receptor, which produces an inhibitory response, hence the “depressive” effects of ethanol beverages.
Over time, alcohol downregulates the GABA receptors, leading to unopposed glutamate activity. Given that glutamate is excitatory, this can lead to seizures.
Alcohol also suppresses REM sleep; in patients with chronically suppressed REM sleep, the brain starves for dream sleep and it spills over into the wakeful state, inducing a dream-like state when someone is awake.
The awake dream-like state of delirium tremens (DT) differs from alcohol hallucinosis
Alcohol hallucinosis presents with visual hallucinations in a wakeful state
DT presents with a generalized clouding of the sensorium and a dream-like state
Treatment for DT is better achieved with phenobarbital due to predictable pharmacology
Phenobarbital acts on GABA and NMDA receptors
References
1. Davies M. The role of GABAA receptors in mediating the effects of alcohol in the central nervous system. J Psychiatry Neurosci. 2003;28(4):263-274.
2. Fujimoto J, Lou JJ, Pessegueiro AM. Use of Phenobarbital in Delirium Tremens. J Investig Med High Impact Case Reports. 2017;5(4):4-6. doi:10.1177/2324709617742166
3. Walker, M. Chapter 13: iPads, Factory Whistles, and Nightcaps In: Walker, M, Why We Sleep. Scribner; 2017, pg. 272.
4. Zarcone V. Alcoholism and sleep. Adv Biosci. 1978;21:29-38.
Summarized & Edited by Jorge Chalit, OMSII
Mon, 24 Jul 2023 - 04min - 1003 - Ukraine Brewtalk Featuring Dr. Dave Young
Contributors: David Young MD, John Hesling MD, Travis Barlock MD, Jeffrey Olson
Summary:
In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss several clips from the event “Ukraine Brewtalk” from October 2022. This event was hosted by the University of Colorado’s Center for COMBAT Research and Emergency Medical Minute assisted in the audio recording of the speakers.
The first clip is of a brief talk by Dr. John Hesling who was presenting some of his research about Pediatric Supermassive Transfusions.
The second and third clips are from the keynote speaker, Dr. Dave Young, an Emergency Medicine Physician at the University of Colorado Hospital, talking about his experience of serving with USA’s Team Rubicon providing medical aid in war-torn Ukraine.
Medical topics discussed include Pediatric trauma, blood transfusions, tourniquet use, refugee care, and blast injuries.
References
Hesling JD, Paulson MW, McKay JT, Bebarta VS, Flarity K, Keenan S, Fisher AD, Borgman MA, April MD, Schauer SG. Characterizing pediatric supermassive transfusion and the contributing injury patterns in the combat environment. Am J Emerg Med. 2022 Jan;51:139-143. doi: 10.1016/j.ajem.2021.10.032. Epub 2021 Oct 24. Erratum in: Am J Emerg Med. 2022 Feb;52:275. PMID: 34739866.
UNHCR. (2023, July 11). Ukraine Refugee Situation. Operational Data Portal. https://data2.unhcr.org/en/situations/ukraine
Ainsley, J. (2023, February 24). U.S. has admitted 271,000 Ukrainian refugees since Russian invasion, far above Biden’s goal of 100,000. NBCNews.com. https://www.nbcnews.com/politics/immigration/us-admits-271000-ukrainian-refugees-russia-invasion-biden-rcna72177
Built to serve. Team Rubicon. https://teamrubiconusa.org/
Summarized by Jeffrey Olson, MS1 | Edited by Jeffrey Olson MS1 and Jorge Chalit, OMSII
Fri, 21 Jul 2023 - 38min - 1002 - Podcast 860: Thyrotoxicosis
Contributor: Travis Barlock MD
Educational Pearls:
Clinical picture: A patient comes in with altered mental status, tachycardia, fever, elevated T4, and low TSH. What’s the diagnosis?... Thyrotoxicosis secondary to Graves’ Disease.
How do you treat thyrotoxicosis?
First, give a beta-blocker such as propranolol. This suppresses the elevated adrenergic activity.
Second, give a thionamide such as propylthiouracil (PTU) or methimazole. This decreases the synthesis of new thyroid hormone. PTU is preferred because it also blocks the conversion of T4 to T3.
Third, give an iodine solution such as potassium iodide. This blocks the release of thyroid hormone through a mechanism called the Wolff-Chaikoff effect. Note, this should be given about an hour after the PTU/methimazole to ensure iodine cannot be taken up and used to synthesize more thyroid hormone in individuals with toxic adenoma or toxic multinodular goiter.
Fourth, give a glucocorticoid such as hydrocortisone. This will reduce thyroid hormone conversion from T4 to T3 and treat any concurrent adrenal insufficiency.
References
Abuid J, Larsen PR. Triiodothyronine and thyroxine in hyperthyroidism. Comparison of the acute changes during therapy with antithyroid agents. J Clin Invest. 1974 Jul;54(1):201-8. doi: 10.1172/JCI107744. PMID: 4134836; PMCID: PMC301541.
Cooper DS, Saxe VC, Meskell M, Maloof F, Ridgway EC. Acute effects of propylthiouracil (PTU) on thyroidal iodide organification and peripheral iodothyronine deiodination: correlation with serum PTU levels measured by radioimmunoassay. J Clin Endocrinol Metab. 1982 Jan;54(1):101-7. doi: 10.1210/jcem-54-1-101. PMID: 6274892.
Das G, Krieger M. Treatment of thyrotoxic storm with intravenous administration of propranolol. Ann Intern Med. 1969 May;70(5):985-8. doi: 10.7326/0003-4819-70-5-985. PMID: 5769631.
Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii. doi: 10.1016/j.ecl.2006.09.008. PMID: 17127140.
Tsatsoulis A, Johnson EO, Kalogera CH, Seferiadis K, Tsolas O. The effect of thyrotoxicosis on adrenocortical reserve. Eur J Endocrinol. 2000 Mar;142(3):231-5. doi: 10.1530/eje.0.1420231. PMID: 10700716.
Summarized by Jeffrey Olson, MS2 | Edited by Jorge Chalit, OMSII
Thu, 20 Jul 2023 - 02min - 1001 - Podcast 859: Teamwork Really Makes the Dream Work
Contributor: Aaron Lessen MD
Educational Pearls:
33 Medical residents and 91 nurses at Massachusetts General Hospital were randomized into two groups:
Intervention group: 15 PGY-1 residents assigned to the same medical service floor for a 16-week period (12 weeks after adjustment for COVID-19 restrictions) alongside 43 nurses.
Control group: 18 PGY-1 residents assigned to the usual 4-week block rotations across 6 medical floors.
At 6 months, there were no differences in teamwork performance metrics including advanced medical simulations and nurse presence at rounds.
The 12-month assessment demonstrated improvement in performance metrics.
Increased time together allows individuals to get to know each other better and therefore improve performance metrics that rely on communication.
References
1. Iyasere CA, Wing J, Martel JN, Healy MG, Park YS, Finn KM. Effect of Increased Interprofessional Familiarity on Team Performance, Communication, and Psychological Safety on Inpatient Medical Teams: A Randomized Clinical Trial. JAMA Intern Med. 2022;182(11):1190-1198. doi:10.1001/jamainternmed.2022.4373
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 10 Jul 2023 - 02min - 1000 - Podcast 858: Whole Blood Pregnancy Test
Contributor: Meghan Hurley MD
Educational Pearls:
What do you do if you need a stat pregnancy test on an incapacitated patient?
You can send a serum quantitative human chorionic gonadotropin (beta-HCG), but that might take a while for the lab to process.
Another option is to place a drop of whole blood on a urine pregnancy immunoassay.
These tests are already verified for urine and serum.
2012 study showed that whole blood was 95.8% sensitive for pregnancy compared to 95.3% for urine.
Takes a little bit longer (10 minutes was used in the study) due to the viscosity of blood.
Word of caution: This study only looked at a single urine pregnancy kit type. It is possible that other kits would have a different efficacy.
There are new finger stick tests coming out for capillary blood.
Anecdotally, Dr. Hurley was able to use this technique to support a diagnosis of ruptured ectopic pregnancy in a patient that needed emergent surgery.
References
Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776.
Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, Grenache DG. Analytical performance evaluation of the i-STAT Total β-human chorionic gonadotropin immunoassay. Clin Chim Acta. 2015 Jun 15;446:165-70. doi: 10.1016/j.cca.2015.04.025. Epub 2015 Apr 25. PMID: 25916696.
Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 03 Jul 2023 - 04min - 999 - Podcast 857: Alice in Wonderland Jeopardy
Contributor: Chris Holmes MD
Educational Pearls:
“It’s a poor sort of memory that only works backwards” - Transient Global Amnesia
A syndrome with sudden retrograde memory loss in which patients cannot retain new information
Characterized by perseveration in frequent intervals
Typically improves within hours
MRI is normal initially
Alice In Wonderland Syndrome
A disorder in which patients experience distortions in their visual perceptions
Most often characterized by micropsia and/or macropsia
Other symptoms may include illusory movement or wavy lines
Alice in Wonderland as a metaphor for birth
Traveling down the rabbit hole is conception
Alice getting bigger in a confined space is pregnancy
Drinking potions is amniotic fluid
Escaping to explore a scary world is childbirth
References
1. Blom JD. Alice in wonderland syndrome. Alice Wonderl Syndr. 2019;(June):1-221. doi:10.1007/978-3-030-18609-8
2. Ropper M.D. AH. Transient Global Amnesia. N Engl J Med. 2023;(388):635-640. doi:10.1056/NEJMra2213867
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 26 Jun 2023 - 03min - 998 - Podcast 856: ED Errors and Counterstudy
Contributor: Nicholas Tsipis, MD
Educational Pearls:
What study was Dr. Tsipis talking about?
In December of 2022, the Agency for Healthcare Research and Quality (AHRQ) put out a study titled “Diagnostic Errors in the Emergency Department: A Systematic Review.”
This study triggered many news stories from prominent outlets with headlines such as, “More than 7 million incorrect diagnoses made in US emergency rooms every year, government report finds,” from CNN, and “E.R. Doctors Misdiagnose Patients With Unusual Symptoms,” from the New York Times.
What was the response?
Matt Bivens, MD from Emergency Medicine News responded to the original study in an article titled, “AHRQ Errors Report was ‘Outright Unconscionable.’”
Dr. Bivens points out that AHRQ’s biggest claims – including that 5.7% of patients are misdiagnosed in the ED and 2.0% suffer an adverse event as a result – were based only on three small studies out of Canada, Spain, and Switzerland (combined n=1,758).
Spain and Switzerland did not have emergency medicine residency-trained physicians at the time of the studies.
The Swiss study looked at when the diagnosis changed significantly between admittance and discharge to which Bivens responded, “Are we describing errors in this study or just an ongoing collaborative process?”
The Canadian study looked at 503 high-acuity patients of which one died of a missed aortic dissection. Bivens notes that this is too small of sample size to be generalized to the American ER population which includes a mix of low and high acuity.
Moral of the story?
Mistakes do happen in the ED and they do negatively impact patients but be careful in how you interpret studies and news articles that report on them.
References
Newman-Toker DE, Peterson SM, Badihian S, Hassoon A, Nassery N, Parizadeh D, Wilson LM, Jia Y, Omron R, Tharmarajah S, Guerin L, Bastani PB, Fracica EA, Kotwal S, Robinson KA. Diagnostic Errors in the Emergency Department: A Systematic Review. Comparative Effectiveness Review No. 258. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 75Q80120D00003.) AHRQ Publication No. 22(23)-EHC043. Rockville, MD: Agency for Healthcare Research and Quality; December 2022. DOI: 10.23970/AHRQEPCCER258.
Kounang, N. (2022, December 16). More than 7 million incorrect diagnoses made in US emergency rooms every year, government report finds. CNN. https://www.cnn.com/2022/12/15/health/hospital-misdiagnoses-study/index.html
Abelson, R. (2022, December 15). E.R. Doctors Misdiagnose Patients With Unusual Symptoms. The New York Times. https://www.nytimes.com/2022/12/15/health/medical-errors-emergency-rooms.html?searchResultPosition=3
Bivens, Matt MD. Evidence-Based Medicine: AHRQ Errors Report was ‘Outright Unconscionable’. Emergency Medicine News 45(3):p 1,21, March 2023. | DOI: 10.1097/01.EEM.0000922716.51556.31
Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 19 Jun 2023 - 04min - 997 - Podcast 855: QT Intervals
Contributor: Travis Barlock MD
Educational Pearls
The QT interval represents phases 2 and 3 of ventricular plateau and repolarization, respectively.
As the QT interval lengthens, more sodium and calcium channels are available and susceptible to action potentials.
Prolonged QT interval is more concerning in the setting of bradycardia.
This scenario increases the likelihood of R on T phenomenon.
R on T phenomenon occurs due to an early afterdepolarization event in which a premature ventricular contraction (PVC) occurs during the repolarization period (superimposed on the T wave), leading to an aberrant re-entry circuit.
The re-entry circuit leads to Torsades de Pointes (polymorphic ventricular tachycardia with prolonged QT) and subsequent ventricular fibrillation.
Treatment for Torsades de Pointes is 2g MgSO4.
The preferred antiarrhythmic for VTach is IV lidocaine 1.5 mg/kg over 2 minutes.
Avoid amiodarone due to risk of further QT prolongation.
A heart rate under 80 does not need QT correction
Corrected QT interval is used in the setting of tachycardia due to an abnormally small T wave
Correction for the QT interval in tachycardia:
472 ms for males vs. 482 ms for females
References
1. Banai S, Schuger C, Benhorin J, Tzivoni D. Treatment of torsade de pointes with intravenous magnesium. Am J Cardiol. 1989;63(20):1539-1540. doi:10.1016/0002-9149(89)90033-7
2. Gorgels APM, Van Den Dool A, Hofs A, et al. Comparison of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia. Am J Cardiol. 1996;78(1):43-46. doi:10.1016/S0002-9149(96)00224-X
3. Liu MB, Vandersickel N, Panfilov A V., Qu Z. R-From-T as a Common Mechanism of Arrhythmia Initiation in Long QT Syndromes. Circ Arrhythmia Electrophysiol. 2019;12(12):1-15. doi:10.1161/CIRCEP.119.007571
4. Sagie A, Larson MG, Goldberg RJ, Bengtson JR, Levy D. An improved method for adjusting the QT interval for heart rate (the Framingham Heart Study). Am J Cardiol. 1992;70(7):797-801. doi:10.1016/0002-9149(92)90562-D
5. Vandenberk B, Vandael E, Robyns T, et al. Which QT correction formulae to use for QT monitoring? J Am Heart Assoc. 2016;5(6). doi:10.1161/JAHA.116.003264
6. Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines. Vol 114.; 2006. doi:10.1161/CIRCULATIONAHA.106.178104
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 12 Jun 2023 - 04min - 996 - Mental Health Monthly #16: Psychosis in the ED Part II
Contributors: Andrew White MD & Travis Barlock MD
In this follow-up episode Dr. Andrew White, a practicing psychiatrist with an addiction medicine fellowship, and Dr. Travis Barlock, an emergency physician at Swedish Medical Center, discuss mental health holds, psychiatric placement, pharmacologic vs. non-pharmacologic treatments, and outpatient care of psychotic patients. If you missed it, be sure to listen to part I for details on the management of psychotic patients in the ED.
Educational Pearls:
Mental health holds should be approached on a case-by-case basis; this includes assessing safety risks immediately, over a 24-hour period, and chronically over the last few months. Lastly, collateral information is useful in assessing a mental health hold.Summarized and edited by Jorge Chalit, OMSII | Studio production by Jeffrey Olson, MS1
Wed, 07 Jun 2023 - 24min - 995 - Episode 854: Tranq (xylazine) with Heroin
Contributor: Aaron Lessen, MD
Educational Pearls:
What is Tranq?
Tranq is the street name for xylazine, a sedative drug typically used in veterinary medicine.
Xylazine has recently emerged as a recreational drug, often mixed with heroin or fentanyl.
The mechanism of action of xylazine is similar to dexmedetomidine (Precedex), an alpha-2 adrenergic receptor agonist.
At toxic levels, either by itself or when combined with opioids, can cause apnea, bradycardia, coma, and hypotension.
How is it different from other adulterants, such as fentanyl?
Because It is not an opioid, naloxone (Narcan) does not reverse its effects.
It may cause local peripheral vasoconstriction leading to necrotic ulcerations at sites of repeated injection.
How do you treat a suspected overdose of Tranq +/- an opioid?
Consult with a clinical toxicologist.
Naloxone should still be used despite its limited effect. At the very least it will not make the situation worse.
Be ready to intubate.
Provide supportive care.
Non-selective alpha antagonists are NOT recommended.
References
Ruiz-Colón K, Chavez-Arias C, Díaz-Alcalá JE, Martínez MA. Xylazine intoxication in humans and its importance as an emerging adulterant in abused drugs: A comprehensive review of the literature. Forensic Sci Int. 2014 Jul;240:1-8. doi: 10.1016/j.forsciint.2014.03.015. Epub 2014 Mar 26. PMID: 24769343.
Ayub S, Parnia S, Poddar K, Bachu AK, Sullivan A, Khan AM, Ahmed S, Jain L. Xylazine in the Opioid Epidemic: A Systematic Review of Case Reports and Clinical Implications. Cureus. 2023 Mar 29;15(3):e36864. doi: 10.7759/cureus.36864. PMID: 37009344; PMCID: PMC10063250.
Malayala SV, Papudesi BN, Bobb R, Wimbush A. Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Philadelphia, Pennsylvania, USA. Cureus. 2022 Aug 19;14(8):e28160. doi: 10.7759/cureus.28160. PMID: 36148197; PMCID: PMC9482722.
United States Drug Enforcement Administration. DEA Reports Widespread Threat of Fentanyl Mixed with Xylazine | DEA.gov. (n.d.). https://www.dea.gov/alert/dea-reports-widespread-threat-fentanyl-mixed-xylazine
Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 05 Jun 2023 - 02min - 994 - Podcast 853: Critical Care Medications - Vasopressors
Contributor: Travis Barlock MD
Educational Pearls:
Three categories of pressors: inopressors, pure vasoconstrictors, and inodilators
Inopressors:
Epinephrine - nonselective beta- and alpha-adrenergic agonism, leading to increased cardiac contractility, chronotropy (increased heart rate), and peripheral vasoconstriction. Dose 0.1mcg/kg/min.
Levophed (norepinephrine) - more vasoconstriction peripherally than inotropy; useful in most cases of shock. Dose 0.1mcg/kg/min.
Peripheral vasoconstrictors:
Phenylephrine - pure alpha agonist; useful in atrial fibrillation because it avoids cardiac beta receptor activation and also in post-intubation hypotension to counteract the RSI medications. Start at 1mcg/kg/min and increase as needed.
Vasopressin - No effect on cardiac contractility. Fixed dose of 0.4 units/min.
Inodilators are useful in cardiogenic shock but often not started in the ED since patients mostly have undifferentiated shock
Dobutamine - start at 2.5mcg/kg/min.
Milrinone - 0.125mcg/kg/min.
References
1. Ellender TJ, Skinner JC. The Use of Vasopressors and Inotropes in the Emergency Medical Treatment of Shock. Emerg Med Clin North Am. 2008;26(3):759-786. doi:https://doi.org/10.1016/j.emc.2008.04.001
2. Hollenberg SM. Vasoactive drugs in circulatory shock. Am J Respir Crit Care Med. 2011;183(7):847-855. doi:10.1164/rccm.201006-0972CI
3. Lampard JG, Lang E. Vasopressors for hypotensive shock. Ann Emerg Med. 2013;61(3):351-352. doi:10.1016/j.annemergmed.2012.08.028
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
Mon, 29 May 2023 - 05min - 993 - Podcast 852: Angioedema After Thrombolysis
Contributor: Aaron Lessen, MD
Educational Pearls:
What is thrombolysis?
Thrombolysis is performed by administration of a medication that promotes the body’s natural ability to break up clots. These medications include Alteplase (tPA) and Tenecteplase (TNK).
The main side effect of using such an agent is bleeding which typically occurs at puncture sites but can also occur internally. However, an unusual side effect of thrombolytic agents, which occurs in about 1-5% of cases, is angioedema.
What is angioedema?
Angioedema is a medical condition that causes swelling beneath the surface of the skin, typically in the face, lips, and throat (orolingual angioedema). Fluid leaks from blood vessels and accumulates in the deeper layers of the skin.
How are these two connected?
The mechanism by which angioedema occurs after thrombolysis is not well understood, but it is likely connected to how tPA can increase levels of bradykinin and histamine.
Swelling can appear suddenly but can also occur up to 24 hours after thrombolysis, and may last for a few hours or several days.
In some cases, angioedema can affect the airways, leading to difficulty breathing.
What can be done?
If this side effect occurs the provider can stop the medication or infusion and treat the patient with anti-histamines, steroids, epinephrine, and airway monitoring.
Medications such as Berinert or Icatibant, typically used in hereditary angioedema or ACE-i-induced angioedema, can also be used but have limited evidence for their efficacy.
Fun fact
tPA-related angioedema is about 4 times more likely in patients on ACE inhibitors. This is likely related to how ACE inhibitors also increase bradykinin and histamine in a patient’s body.
References
Zhu A, Rajendram P, Tseng E, Coutts SB, Yu AYX. Alteplase or tenecteplase for thrombolysis in ischemic stroke: An illustrated review. Res Pract Thromb Haemost. 2022 Sep 20;6(6):e12795. doi: 10.1002/rth2.12795. PMID: 36186106; PMCID: PMC9487449.
Pahs L, Droege C, Kneale H, Pancioli A. A Novel Approach to the Treatment of Orolingual Angioedema After Tissue Plasminogen Activator Administration. Ann Emerg Med. 2016 Sep;68(3):345-8. doi: 10.1016/j.annemergmed.2016.02.019. Epub 2016 May 10. PMID: 27174372.
Burd M, McPheeters C, Scherrer LA. Orolingual Angioedema After Tissue Plasminogen Activator Administration in Patients Taking Angiotensin-Converting Enzyme Inhibitors. Adv Emerg Nurs J. 2019 Jul/Sep;41(3):204-214. doi: 10.1097/TME.0000000000000250. PMID: 31356244.
Sczepanski M, Bozyk P. Institutional Incidence of Severe tPA-Induced Angioedema in Ischemic Cerebral Vascular Accidents. Crit Care Res Pract. 2018 Sep 27;2018:9360918. doi: 10.1155/2018/9360918. PMID: 30363665; PMCID: PMC6180929.
Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS1
Mon, 22 May 2023 - 02min - 992 - Podcast 851: High-Dose Nitroglycerin in SCAPE
Contributor: Aaron Lessen MD
Educational Pearls:
SCAPE (Sympathetic Crashing Acute Pulmonary Edema), formerly known as flash pulmonary edema, is a life-threatening condition due to a sudden sympathetic surge that leads to hypertensive heart failure, pulmonary edema, hypoxia, and respiratory distress. The initial treatment for SCAPE stabilization is BiPAP to assist with ventilation. Pharmacological treatment for SCAPE is best achieved with high-dose nitroglycerin (HDN), which induces venodilation and redistributes pulmonary edema. Dosing should be high; boluses of HDN are given at doses of 1-2 mg every 3-5 minutes vs. infusions at 200-400 mcg/min then titrating down. HDN leads to reduced intubations, less need for ICU admission, and shortened length of hospital stay in patients with SCAPE.References
Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719-723. doi:10.4103/0972-5229.195710
Paone S, Clarkson L, Sin B, Punnapuzha S. Recognition of Sympathetic Crashing Acute Pulmonary Edema (SCAPE) and use of high-dose nitroglycerin infusion. Am J Emerg Med. 2018;36(8):1526.e5-1526.e7. doi:https://doi.org/10.1016/j.ajem.2018.05.013
Stemple K, DeWitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series. Am J Emerg Med. 2021;44:262-266. doi:https://doi.org/10.1016/j.ajem.2020.03.062
Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-131. doi:https://doi.org/10.1016/j.ajem.2016.10.038
Summarized by Jorge Chalit, OMS1 | Edited by Meg Joyce & Jorge Chalit, OMS1
Mon, 15 May 2023 - 03min - 991 - Podcast 850: Cardiac Arrest - Entertainment vs. Reality
Contributor: Travis Barlock, MD
Educational Pearls:
Sudden Cardiac Arrest (SCA) is defined as when the heart suddenly stops beating. Immediate treatment for SCA includes Cardiopulmonary Resuscitation (CPR) and defibrillation. This event is commonly depicted in medical dramas as an intense moment but often with the patient surviving and making a full recovery (67-75%). This depiction has likely led the general population astray when it comes to the true survivability of SCA. When surveyed, the general population tends to believe that in excess of 50% of patients requiring CPR survive and return to daily life with no long-term consequences.
What percent of patients actually survive cardiac arrest?
SCA due to Ventricular Fibrillation (VF): 25-40%
SCA due to Pulseless Electrical Activity (PEA): 11%
SCA due to noncardiac causes (trauma ect.): 11%
SCA when the initially observed rhythm is Asystole: Less than 5%, by some measures as low as 2%.
References
Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med. 1996 Jun 13;334(24):1578-82. doi: 10.1056/NEJM199606133342406. PMID: 8628340.
Bitter CC, Patel N, Hinyard L. Depiction of Resuscitation on Medical Dramas: Proposed Effect on Patient Expectations. Cureus. 2021 Apr 11;13(4):e14419. doi: 10.7759/cureus.14419. PMID: 33987068; PMCID: PMC8112599.
Engdahl J, Bång A, Lindqvist J, Herlitz J. Can we define patients with no and those with some chance of survival when found in asystole out of hospital? Am J Cardiol. 2000 Sep 15;86(6):610-4. doi: 10.1016/s0002-9149(00)01037-7. PMID: 10980209.
Cobb LA, Fahrenbruch CE, Walsh TR, Copass MK, Olsufka M, Breskin M, Hallstrom AP. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA. 1999 Apr 7;281(13):1182-8. doi: 10.1001/jama.281.13.1182. PMID: 10199427.
Rea TD, Eisenberg MS, Becker LJ, Murray JA, Hearne T. Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective. Circulation. 2003 Jun 10;107(22):2780-5. doi: 10.1161/01.CIR.0000070950.17208.2A. Epub 2003 May 19. PMID: 12756155.
Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O'Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM; Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916. Epub 2020 Oct 21. PMID: 33081529.
Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS1
Mon, 08 May 2023 - 02min - 990 - Mental Health Monthly #15: Psychosis in the ED: Part I
Contributors: Andrew White MD & Travis Barlock MD
In this episode of Mental Health Monthly, Dr. Andrew White, a practicing psychiatrist with an addiction medicine fellowship, and Dr. Travis Barlock, an emergency physician at Swedish Medical Center, discuss the various presentations and etiologies of acute psychosis. They explore the medical presentations compared with primary psychiatric manifestations and how to narrow the differential. Furthermore, Dr. Barlock discusses the management of psychotic patients from the ED perspective while Dr. White provides invaluable insight into their respective psychiatric care.
Educational Pearls:
Auditory hallucinations are more consistent with primary psychiatric psychosis, whereas visual hallucinations are indicative of drug-induced or withdrawal psychosis. Negative symptoms in schizophrenia can be remembered by the four A’s: Alogia, Affect, Ambivalence, and Associations. Typical primary psychosis presents before age 40, except for in perimenopausal and post-partum women, who are at higher risk of psychiatric psychosis. Medical etiology clues: acute and rapid onset, focal neurologic deficits, abnormal vital signs (especially fever), drugs, endocrine sources, autoimmune diseases, infectious disease, and brain lesions. To LP or not to LP? Dr. Barlock discusses indications for LP including fever, rapid onset, and change in level of consciousness.Summarized by Jorge Chait, OMSI | Edited by Jorge Chalit, OMSI | Studio production by Jeffrey Olson
Wed, 03 May 2023 - 31min - 989 - Podcast 849: Large Vessel Occlusions
Contributor: Travis Barlock MD
Educational Pearls:
Large Vessel Occlusion (LVO) is a condition where a clot blocks one of the major blood vessels in the brain, leading to a stroke.
What are the vessels that can experience an LVO?
Middle Cerebral artery (MCA)
Internal Carotid Artery (ICA)
Anterior Cerebral Artery (ACA)
Posterior Cerebral Arteries (PCA)
Basilar Artery (BA)
Vertebral Arteries (VA)
What are the locations at which a mechanical thrombectomy can be performed as a treatment for an LVO?
Distal ICA, M1 or M2 segments of the MCA, A1 or A2 segments of the ACA, and some evidence for the BA.
What are the symptoms of LVO?
Use the mnemonic FANG-D to remember a few key symptoms:
Field Cut (A person loses vision in a portion of their visual field)
Aphasia (Difficulty speaking)
Neglect (A person may have difficulty paying attention to or acknowledging stimuli on the affected side of their body or in their environment. For example, a person with neglect may deny that their left hand belongs to them)
Gaze Deviation (One or both eyes are turned away from the direction of gaze)
Dense Hemiparesis (Paralysis affecting one side of the body)
What are the treatment windows for treating an LVO?
24 hours for mechanical thrombectomy
0-4.5 hours for tPA/TNK
References
1. Brain embolism, Caplan LR, Manning W (Eds), Informa Healthcare, New York 2006.
2. Berkhemer OA, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015 Jan 1;372(1):11-20. doi: 10.1056/NEJMoa1411587. Epub 2014 Dec 17. Erratum in: N Engl J Med. 2015 Jan 22;372(4):394. PMID: 25517348.
3. Herpich, Franziska MD1,2; Rincon, Fred MD, MSc, MB.Ethics, FACP, FCCP, FCCM1,2. Management of Acute Ischemic Stroke. Critical Care Medicine 48(11):p 1654-1663, November 2020.
4. Warner JJ, Harrington RA, Sacco RL, Elkind MSV. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke. 2019 Dec;50(12):3331-3332. doi: 10.1161/STROKEAHA.119.027708. Epub 2019 Oct 30. PMID: 31662117.
5. Hoglund J, Strong D, Rhoten J, Chang B, Karamchandani R, Dunn C, Yang H, Asimos AW. Test characteristics of a 5-element cortical screen for identifying anterior circulation large vessel occlusion ischemic strokes. J Am Coll Emerg Physicians Open. 2020 Jul 24;1(5):908-917. doi: 10.1002/emp2.12188. PMID: 33145539; PMCID: PMC7593424.
Summarized by Jeffrey Olson | Edited by Meg Joyce & Jorge Chalit, OMS1
Mon, 01 May 2023 - 03min - 988 - Podcast 848: Non-Traditional RSI
Contributor: Meghan Hurley, MD
Educational Pearls:
Two main reasons to choose non-traditional RSI
Anatomically challenging airway
Physiologically difficult patients: hypoxia, metabolic acidosis, hemodynamic instability
Ketamine may help patients remain hemodynamically stable
In critical patients, it is important to consider non-traditional RSI medications to improve outcomes
References
1. Lyon RM, Perkins ZB, Chatterjee D, Lockey DJ, Russell MQ. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care. 2015;19(1). doi:10.1186/s13054-015-0872-2
2. Merelman AH, Perlmutter MC, Strayer RJ. Alternatives to rapid sequence intubation: Contemporary airway management with ketamine. West J Emerg Med. 2019;20(3):466-471. doi:10.5811/westjem.2019.4.42753
Summarized by Jorge Chalit, OMS1 | Edited by Meg Joyce
Mon, 24 Apr 2023 - 05min - 987 - Podcast 847: ECMO CPR
Contributor: Aaron Lessen, MD
Educational Pearls:
Extracorporeal Membrane Oxygenation (ECMO) has been attempted as an adjunct to CPR during cardiac arrest but few studies on outcomes exist One prior small study stopped early when it showed ECMO with CPR (ECPR) was significantly superior to CPR Recent large, multicenter randomized control study in Netherlands evaluated neurologic outcomes in CPR versus ECPR At 30 days and 6 months no significant difference between the groups was found More studies are required determine if certain patients may benefit from ECPRReferences
Belohlavek J, Smalcova J, Rob D, et al. Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2022;327(8):737-747. doi:10.1001/jama.2022.1025
Suverein MM, Delnoij TSR, Lorusso R, et al. Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. N Engl J Med. 2023;388(4):299-309. doi:10.1056/NEJMoa2204511
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.
Mon, 06 Feb 2023 - 03min - 986 - Podcast 846: Early Repolarization vs. Anterior STEMI
Contributor: Travis Barlock, MD
Educational Pearls:
Early repolarization a benign EKG pattern that can mimic an anterior STEMI Can be seen in the anterior leads typically in young male patients Can differentiate Early Repolarization vs Anterior STEMI by looking at four variables: Corrected QT interval QRS amplitude in V2 R wave amplitude in V4 ST elevation 60 ms after J point in V3 These four variables can be plugged into a formula (available on MDCalc) Note that a longer QT is more corelated with STEMIReferences
Macfarlane PW, Antzelevitch C, Haissaguerre M, et al. The Early Repolarization Pattern: A Consensus Paper. J Am Coll Cardiol. Jul 28 2015;66(4):470-7. doi:10.1016/j.jacc.2015.05.033
Smith SW, Khalil A, Henry TD, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med. Jul 2012;60(1):45-56.e2. doi:10.1016/j.annemergmed.2012.02.015
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.
Mon, 30 Jan 2023 - 02min - 985 - Podcast 845: Hyperkalemic Cardiac Arrest
Contributor: Aaron Lessen, MD
Educational Pearls:
Hyperkalemia may cause cardiac arrest Treatment of suspected hyperkalemic cardiac arrest begins with typical management of cardiac arrest including high-quality CPR, defibrillation if appropriate, and resuscitation medications Administer calcium products to stabilize cardiac membrane and potassium shifting medications If ROSC is achieved, initiate dialysis There are several case reports of patients being dialyzed while CPR is ongoing, with some success Dialysis during resuscitation may be an appropriate treatment for some patientsReferences
Jackson MA, Lodwick R, Hutchinson SG. Hyperkalaemic cardiac arrest successfully treated with peritoneal dialysis. BMJ. 1996;312(7041):1289-1290. doi:10.1136/bmj.312.7041.1289
Kao KC, Huang CC, Tsai YH, Lin MC, Tsao TC. Hyperkalemic cardiac arrest successfully reversed by hemodialysis during cardiopulmonary resuscitation: case report. Chang Gung Med J. 2000;23(9):555-559.
Torrecilla C, de la Serna JL. Hyperkalemic cardiac arrest, prolonged heart massage and simultaneous hemodialysis. Intensive Care Med. 1989;15(5):325-326. doi:10.1007/BF00263870
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.
Mon, 16 Jan 2023 - 04min - 984 - Podcast 844: Dental Infections
Contributor: Meghan Hurley, MD
Educational Pearls:
Educational Pearls:
Dental infections can be categorized into two main groups Infections of the gums Pericoronitis Tooth eruption leading to inflammation/irritation Can progress to an infection Requires pain control, no antibiotics Gingivitis Inflammation of the gums Can lead to an infection requiring antibiotics Abscess (gums) If an infection develops in the gums it can progress to an abscess May require drainage Acute necrotizing ulcerative gingivitis (ANUG) aka Trench Mouth Filmy, grayish discoloration of the gums with “punched out” lesions Extremely painful Can cause teeth to loosen and fall out Treat with IV antibiotics + admission Infections of the teeth Dental caries Causes sensitivity tooth enamel is worn through Can lead to infection Periapical abscess Abscess that extends through the root of the tooth Can develop up elsewhere in tooth/gums/mouth Causes tooth sensitivity when tapped Ludwig angina Infection of the soft tissue under the tongue Can compromise airway as it expands Treat with extensive antibiotics and debridement Antibiotic stewardship Commonly used antibiotics for dental infections Clindamycin Augmentin Amoxicillin Chlorhexidine (Peridex) Antiseptic and disinfectant that is helpful for gingival irritationReferences
Bridwell R, Gottlieb M, Koyfman A, Long B. Diagnosis and management of Ludwig's angina: An evidence-based review. Am J Emerg Med. Mar 2021;41:1-5. doi:10.1016/j.ajem.2020.12.030
Dufty J, Gkranias N, Donos N. Necrotising Ulcerative Gingivitis: A Literature Review. Oral Health Prev Dent. 2017;15(4):321-327. doi:10.3290/j.ohpd.a38766
Herrera D, Roldán S, Sanz M. The periodontal abscess: a review. J Clin Periodontol. Jun 2000;27(6):377-86. doi:10.1034/j.1600-051x.2000.027006377.x
Kumar S. Evidence-Based Update on Diagnosis and Management of Gingivitis and Periodontitis. Dent Clin North Am. Jan 2019;63(1):69-81. doi:10.1016/j.cden.2018.08.005
Kwon G, Serra M. Pericoronitis. StatPearls. StatPearls Publishing
Copyright © 2022, StatPearls Publishing LLC.; 2022.
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.
Tue, 10 Jan 2023 - 04min - 983 - Podcast 843: Commotio Cordis
Contributor: Jared Scott, MD
Educational Pearls:
Commotio cordis is sudden ventricular fibrillation precipitated by direct impact to the chest A national registry, US Commotio Cordis Registry, reports an average of 10-20 cases annually 95% of reported cases occur in males, indicating possible genetic component Average age of patient in registry is 15 Most cases occur during sporting events (baseball in particular), in addition to physical altercations and industrial accidents Treatment is high quality CPR and early defibrillation Survival rate is improving but remains around 35% In recent events, American football player Damar Hamlin survived a Commotio cordis event after being tackled on field and receiving CPRReferences
Link MS. Commotio cordis: ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circ Arrhythm Electrophysiol. 2012;5(2):425-432. doi:10.1161/CIRCEP.111.962712
Maron BJ, Poliac LC, Kaplan JA, Mueller FO. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N Engl J Med. 1995;333(6):337-342. doi:10.1056/NEJM199508103330602
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.
Mon, 09 Jan 2023 - 04min - 982 - Podcast 842: “History of Wound Care”
Contributor: Chris Holmes, MD
Educational Pearls:
Through world history, there have been various interesting approaches to wound care Ancient Egyptians applied honey, lint, and grease which provided antimicrobial, absorptive and moisturizing properties, respectively Ancient Greeks irrigated wounds with clean water and applied wine and vinegar which may have been antimicrobial One of the first synthetic topical antimicrobials was a dye researched by scientist Gerhard Domagk and later produced by Bayer under the name Prontosil Some current wound care methods include wet-to-dry dressings, Dankin’s Solution (sodium hypochlorite) and the use of maggotsReferences
Fleck CA. Why "wet to dry"?. J Am Col Certif Wound Spec. 2009;1(4):109-113. Published 2009 Oct 6. doi:10.1016/j.jcws.2009.09.003
Shah JB. The history of wound care. J Am Col Certif Wound Spec. 2011;3(3):65-66. doi:10.1016/j.jcws.2012.04.002
Ueno CM, Mullens CL, Luh JH, Wooden WA. Historical review of Dakin's solution applications. J Plast Reconstr Aesthet Surg. 2018;71(9):e49-e55. doi:10.1016/j.bjps.2018.05.023
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.
Wed, 04 Jan 2023 - 04min - 981 - Podcast 841: Wound Care
Contributor: Aaron Lessen, MD
Educational Pearls:
Wound care in the emergency department aims to prevent future infection Copious wound irrigation is the important step in preventing wound infection Studies have shown that irrigation with tap water is just as effective, if not superior, to irrigation with saline or other solutions Several studies have shown no reduction in wound infection rates when using sterile gloves during wound care Recent study in the Netherlands compared infection rates between patients undergoing wound repair with and without sterile gloves Receiving wound care with nonsterile gloves was noninferior to wound care utilizing sterile glovesReferences
Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. Feb 15 2012;(2):Cd003861. doi:10.1002/14651858.CD003861.pub3
Heckmann N, Simcox T, Kelley D, Marecek GS. Wound Irrigation for Open Fractures. JBJS Rev. Jan 2020;8(1):e0061. doi:10.2106/jbjs.Rvw.19.00061
Zwaans JJM, Raven W, Rosendaal AV, et al. Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre randomised controlled trial. Emerg Med J. Sep 2022;39(9):650-654. doi:10.1136/emermed-2021-211540
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.
Tue, 03 Jan 2023 - 03min - 980 - Podcast 840: Abnormal Pediatric Vitals at Discharge
Contributor: Aaron Lessen, MD
Educational Pearls:
Pediatric patients frequently have vital signs considered abnormal for age at discharge Large multicenter study recently evaluated if pediatric patients discharged with abnormal vital signs have worse outcomes 97,824 pediatric discharges were included in the study 18.1% were discharged with vitals considered abnormal for age No significant difference in readmission rates at 48 hours (2.28% in abnormal cohort vs. 2.45% in normal cohort) No significant adverse outcomes in those discharged with abnormal vital signs (4 total PICU admissions with no deaths, CPR, or intubations) When considering discharging pediatric patients, it is important to evaluate how the patient looks rather than just relying on vital signs Consider leaving the child attached to a monitor, leaving the room, and then reevaluating them if they could be agitated by the presence of healthcare providersReferences
Kazmierczak M, Thompson AD, DePiero AD, Selbst SM. Outcomes of patients discharged from the pediatric emergency department with abnormal vital signs. Am J Emerg Med. Jul 2022;57:76-80. doi:10.1016/j.ajem.202
Image from:
Vital Signs. MedlinePlus. https://medlineplus.gov/vitalsigns.html. Accessed December 29, 2022.
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.
Thu, 29 Dec 2022 - 03min - 979 - Podcast 839: Causes of Pancreatitis
Contributor: Travis Barlock, MD
Educational Pearls:
The causes of pancreatitis can be remembered with the mnemonic: “GET SMASHED” G: Gallstones (Most common cause of pancreatitis overall) E: Ethanol (Alcohol consumption is the most common cause of chronic pancreatitis) T: Trauma S: Steroids M: Malignancy A: Autoimmune S: Scorpion Sting H: Hypertryglyceridemia E: ERCP D: Drugs (e.g. Valproate, Antiretrovirals)References
Beyer G, Habtezion A, Werner J, Lerch MM, Mayerle J. Chronic pancreatitis. Lancet. 2020;396(10249):499-512. doi:10.1016/S0140-6736(20)31318-0
Lankisch PG, Apte M, Banks PA. Acute pancreatitis [published correction appears in Lancet. 2015 Nov 21;386(10008):2058]. Lancet. 2015;386(9988):85-96. doi:10.1016/S0140-6736(14)60649-8
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Mon, 19 Dec 2022 - 03min - 978 - Podcast 838: Sternoclavicular Septic ArthritisTue, 13 Dec 2022 - 04min
- 977 - Podcast 837: Snakebites
Contributor: Meghan Hurley, MD
Educational Pearls:
Venomous snakes in the United States include species from the family Elapidae and subfamily Crotalinae In prehospital setting, elevate the bitten extremity and transport to hospital immediately Do not attempt interventions with the bite site Monitor for progression of swelling past any joint line, systemic symptoms or lab abnormalities for 8-12 hours Symptoms may present up to hours after bite Crotalinae venom has heme toxicity and may present with lab pattern of DIC Treatment for all symptoms is antivenom If symptoms persist or progress, continue to treat with antivenom Compartment syndrome is rare with snake bitesReferences
Ruha AM, Kleinschmidt KC, Greene S, et al. The Epidemiology, Clinical Course, and Management of Snakebites in the North American Snakebite Registry. J Med Toxicol. 2017;13(4):309-320. doi:10.1007/s13181-017-0633-5
Aziz H, Rhee P, Pandit V, Tang A, Gries L, Joseph B. The current concepts in management of animal (dog, cat, snake, scorpion) and human bite wounds. J Trauma Acute Care Surg. 2015;78(3):641-648. doi:10.1097/TA.0000000000000531
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Mon, 12 Dec 2022 - 06min - 976 - Podcast 836: Humming to get EJ
Contributor: Jared Scott, MD
Educational Pearls:
Two conventional ways to aid in external jugular vein (EJ) catheter placement are Trendelenburg’s position and Valsalva’s maneuver by patient One study compared ultrasound visualization of cross sections of EJ and common femoral vein at baseline and with patients in Trendelenburg's position, Valsalva's maneuver, and while humming The study found all three conditions distended the veins from baseline, but there was no significant difference in diameter between the conditions Humming may be a viable technique in distended EJ for catheter placement, and may be easier for patients to comprehend than ValsalvaReferences
Lewin MR, Stein J, Wang R, et al. Humming is as effective as Valsalva's maneuver and Trendelenburg's position for ultrasonographic visualization of the jugular venous system and common femoral veins. Ann Emerg Med. 2007;50(1):73-77. doi:10.1016/j.annemergmed.2007.01.024
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Tue, 06 Dec 2022 - 03min - 975 - Podcast 835: Syncope Review
Contributor: Meghan Hurley, MD
Educational Pearls:
Syncope is defined as a loss of consciousness with an immediate return to baseline Differential is broad Cardiogenic Structural (aortic stenosis, HOCUM, etc.) Electrical (long QT syndrome, Brugada, etc.) Neurogenic/neurovascular (brain bleed, etc.) Seizure Everything else Hypoglycemia, anemia, and bleeding into the abdominal cavity are some potential causes to rule out Vasovagal Diagnosis of exclusion Work Up EKG Good H&P Labs especially Hb and glucoseReferences
Morris J. Emergency department management of syncope. Emerg Med Pract. Jun 2021;23(6):1-24.
Reed MJ. Approach to syncope in the emergency department. Emerg Med J. Feb 2019;36(2):108-116. doi:10.1136/emermed-2018-207767
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Mon, 05 Dec 2022 - 06min - 974 - Podcast 834: Peds Buckle Fractures
Contributor: Aaron Lessen, MD
Educational Pearls:
Torus (Buckle) fractures are a commonly encountered pediatric fracture pattern Typically presents as wrist pain secondary to a child falling on outstretched hand One edge of the bone “buckles” or bends because children’s bones are softer and more pliable Management Older studies have shown that short term immobilization with a velcro splint and primary care follow up is sufficient Recent randomized trial compared immobilization with Velcro splint with as needed wrist support using a gauze wrap No significant differences noted in outcomes between the two cohorts Physicians can consider using an ace or gauze wrap as needed for buckle fracture management along with OTC analgesics for pain managementReferences
Asokan A, Kheir N. Pediatric Torus Buckle Fracture. StatPearls. StatPearls Publishing
Copyright © 2022, StatPearls Publishing LLC.; 2022.
Kennedy SA, Slobogean GP, Mulpuri K. Does degree of immobilization influence refracture rate in the forearm buckle fracture? J Pediatr Orthop B. Jan 2010;19(1):77-81. doi:10.1097/BPB.0b013e32832f067a
Perry DC, Achten J, Knight R, et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet. Jul 2 2022;400(10345):39-47. doi:10.1016/s0140-6736(22)01015-7
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Tue, 29 Nov 2022 - 03min - 973 - Podcast 833: NS vs LR
Contributor: Travis Barlock, MD
Educational Pearls:
Normal Saline (NS) contains 154 mEq of both Sodium (Na) and Chloride (Cl), and has a pH of 5.5 Normal Na and Cl in adult humans are about 140 mEq/L and 103 mEq/L. respectively Excess negative charge resulting from hyperchloremia is managed via bicarbonate excretion leading to loss of base Overall, administration of NS drives metabolic acidosis Lactated Ringers (LR) contains 130 mEq of Na and 109 mEq Cl, and has a pH of 6.5 LR components are closer to physiologic levels thus may generally be a more efficacious fluid choice NS is still frequently given in scenarios where there is concern for increased intracranial pressure or existing hypochloremic alkalosis from emesis.ReferencesLi H, Sun SR, Yap JQ, Chen JH, Qian Q. 0.9% saline is neither normal nor physiological. J Zhejiang Univ Sci B. 2016;17(3):181-187. doi:10.1631/jzus.B1500201
Lehr AR, Rached-d'Astous S, Barrowman N, et al. Balanced Versus Unbalanced Fluid in Critically Ill Children: Systematic Review and Meta-Analysis. Pediatr Crit Care Med. 2022;23(3):181-191. doi:10.1097/PCC.0000000000002890
Self WH, Semler MW, Wanderer JP, et al. Saline versus balanced crystalloids for intravenous fluid therapy in the emergency department: study protocol for a cluster-randomized, multiple-crossover trial. Trials. 2017;18(1):178. Published 2017 Apr 13. doi:10.1186/s13063-017-1923-6
Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829-839. doi:10.1056/NEJMoa1711584
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Mon, 28 Nov 2022 - 05min - 972 - CA Bridge Program and Health Disparities in the Opioid Epidemic
Happy Thanksgiving EMM listeners, Mason here wanting to extend a special thank you to all of you for tuning in to our show. Today we are featuring a special episode on health disparities in the opioid epidemic and their intersection with the ER that we produced for the Iowa Healthcare Collaborative’s Compass Opioid Stewardship Program, a national initiative to provide comprehensive education on opioid stewardship and best practices.
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Wed, 23 Nov 2022 - 51min - 971 - Podcast 832: STD Checks
Educational Pearls:
Most common sexually transmitted disease (STD) in North America: Human Papillomavirus (HPV) From the emergency department patients should be connected to follow-up care and educated on vaccine series Most common non-viral STD in North America: Trichomonas Vaginalis While men may be asymptomatic, they can transmit the disease to women who may experience irritation leading to increased likelihood of PID and contraction of other STDs and HIV Trichomonas is diagnosed via wet preparation with visualization of motile parasites Similarly, men’s urine can be tested for visualized motile parasites Expedite lab as parasites are motile for about one hour PCR test is becoming more available Most common bacterial STD in North America: Chlamydia trachomatis Neisseria gonorrhoeae is a less common bacterial STD but does have high rates of drug resistance Empiric STD treatment includes IM Ceftriaxone and PO Doxycycline Providers should consider adding Flagyl for Trichomonas Vaginalis coverageReferencesSexually transmitted disease surveillance, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/std/statistics/2020/default.htm. Published August 22, 2022. Accessed November 21, 2022.
Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. Published 2021 Jul 23. doi:10.15585/mmwr.rr7004a1
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Tue, 22 Nov 2022 - 05min - 970 - Podcast 831: O2 Targets
Contributor: Aaron Lessen,MD
Educational Pearls:
Recent study looked at mechanically ventilated patients in ED and ICU to determine if O2 saturation level impacted patient outcomes 2541 patients randomized to one of three target O2 saturation levels Low: 90% (Range: 88-92%) Intermediate: 94% (Range: 92-96%) High: 98% (Range: 96-100%) Outcome indicators Primary: Number of days alive and ventilator free by day 28 of hospital admission Secondary: Mortality at 28 days No significant difference was seen for either primary or secondary outcomes between all three groups at 28 days This study shows that the target oxygenation level is not likely to significantly impact outcomes in mechanically ventilated patients in the EDReferences
Semler MW, Casey JD, Lloyd BD, et al. Oxygen-Saturation Targets for Critically Ill Adults Receiving Mechanical Ventilation. N Engl J Med. Nov 10 2022;387(19):1759-1769. doi:10.1056/NEJMoa2208415
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Mon, 21 Nov 2022 - 03min - 969 - Podcast 830: Peripheral IV Flow Rates
Contributor: Travis Barlock, MD
Educational Pearls:
Gauge and length of catheter are determinants of flow rate Smaller gauges produce higher flow rate Longer catheters reduce flow rate Common IV gauges produce predictable rates of flow: 20 gauge = 60 cc/min 18 gauge = 105 cc/min 16 gauge = 220 cc/min Central lines typically have two 18 gauge and one 16 gauge lumen, both with long catheters, producing the following slower flow rates: 18 gauge = 26 cc /min 16 gauge = 55 cc/min Sheath Introducers, such as Cordis brand catheters, are wider and shorter than classic central lines. Flow rates are 150 cc/min, or 130 cc/min with pressure bag Maximal flow allows for one unit of blood to be delivered over one minute It is important to consider length and gauge of catheter when patients require fluidsReferences
Greene N, Bhananker S, Ramaiah R. Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma. International Journal of Critical Illness and Injury Science. 2012;2(3):135. doi:10.4103/2229-5151.100890
Khoyratty SI, Gajendragadkar PR, Polisetty K, Ward S, Skinner T, Gajendragadkar PR. Flow rates through intravenous access devices: an in vitro study. J Clin Anesth. 2016;31:101-105. doi:10.1016/j.jclinane.2016.01.048
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Tue, 15 Nov 2022 - 03min - 968 - Podcast 829: Monkeypox
Contributor: Aaron Lessen, MD
Educational Pearls:
Monkeypox transmission is still occurring in the United States Transmitted by contact to exposed lesion MSM are a high-risk group for monkeypox infection Symptoms include rash and flu like symptoms Monkeypox lesions are often described as blister-like, firm, clear, and rubbery Most commonly develop on the face and/or anogenital regions Patients with potential monkeypox infection should be moved to isolation to reduce risk of transmission Providers should use full PPE including N95, facial covering, gown, and gloves when interacting with a potential case of monkeypox Diagnosis involves swabbing the lesion and sending it for analysis People at risk for severe disease (i.e. immunocompromised) or who have severe symptoms (i.e. eye involvement) should begin treatment with Tecovirimat (TPOXX) in the ED Infectious Disease (ID) should be consulted, and the patient will need to follow up with ID regardless of symptom severityReferences
Rizk JG, Lippi G, Henry BM, Forthal DN, Rizk Y. Prevention and Treatment of Monkeypox. Drugs. Jun 2022;82(9):957-963. doi:10.1007/s40265-022-01742-y
Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022. N Engl J Med. Aug 25 2022;387(8):679-691. doi:10.1056/NEJMoa2207323
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Mon, 14 Nov 2022 - 04min - 967 - Podcast 828: TXA Dosing Update
Contributor: Nick Hatch, MD
Educational Pearls:
In the setting of traumatic injury, tranexamic acid (TXA) is given to stabilize clots which minimizes bleeding and decreases risk of hemorrhagic shock Current TXA dose for trauma is 1 g bolus followed by a 1 g infusion; both doses should be given within 3 hours from time of injury Due to the split dose and narrow window, patients with complicated care, particularly if they require transfer may miss the infusion dose Various smaller studies have shown that dosing 2 g initially or 2 g followed by a 1 g infusion produces the same patient outcomes and no additional harm Receiving hospitals should strive to acquire accurate information regarding previous doses of TXA given and confirm timeline of injuryReferences
Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013;17(10):1-79. doi:10.3310/hta17100
Ramirez RJ, Spinella PC, Bochicchio GV. Tranexamic Acid Update in Trauma. Crit Care Clin. 2017;33(1):85-99. doi:10.1016/j.ccc.2016.08.004
Spinella PC, Thomas KA, Turnbull IR, et al. The Immunologic Effect of Early Intravenous Two and Four Gram Bolus Dosing of Tranexamic Acid Compared to Placebo in Patients With Severe Traumatic Bleeding (TAMPITI): A Randomized, Double-Blind, Placebo-Controlled, Single-Center Trial. Front Immunol. 2020;11:2085. Published 2020 Sep 8. doi:10.3389/fimmu.2020.02085
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Tue, 08 Nov 2022 - 04min - 966 - Podcast 827: Allergies in Peds
Contributor: Aaron Lessen, MD
Educational Pearls:
Recent study evaluated if early exposure to an allergen impacted the rate of allergy development later in childhood Children were exposed to peanut, milk, wheat, and egg allergens at 3 months of age and then followed for 3 years 2.5-3% of children who were not exposed developed allergies to these allergens 1% of children exposed to the allergens developed allergies to these allerrgens Exposing 63 children to allergens at 3 months would prevent the development of food allergy in one child with no significant adverse events Future recommendations will likely be to gradually introduce allergens to children starting around 3 monthsReferences
Skjerven HO, Lie A, Vettukattil R, et al. Early food intervention and skin emollients to prevent food allergy in young children (PreventADALL): a factorial, multicentre, cluster-randomised trial. Lancet. Jun 25 2022;399(10344):2398-2411. doi:10.1016/s0140-6736(22)00687-0
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Mon, 07 Nov 2022 - 02min - 965 - Podcast 826: STEMI Equivalents
Contributor: Travis Barlock, MD
Educational Pearls:
The presence of a STEMI has traditionally been used to determine if a patient with acute chest pain requires urgent cath lab management STEMI indicates an occluded coronary artery, and urgent intervention is needed to restore perfusion to ischemic tissue Patients with occluded coronary arteries can present with EKG findings other than STEMI 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department was recently published in the Journal of the American College of Cardiology Recognizes STEMI equivalents that necessitate cath lab management ST depression in precordial leads Indicates a posterior infarct/possible RCA occlusion LBBB c ST elevation meeting modified Sgarbossa criteria Hyperacute and/or De Winter T wave First indication of coronary artery occlusion Most beneficial time to initiate cath lab because more tissue is salvageable These recommendations will likely alter clinical practice for ED management of acute chest painReferences
Kontos MC, de Lemos JA, Deitelzweig SB, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. Oct 6 2022;doi:10.1016/j.jacc.2022.08.750
Meyers HP, Bracey A, Lee D, et al. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med. Mar 2021;60(3):273-284. doi:10.1016/j.jemermed.2020.10.026
Tziakas D, Chalikias G, Al-Lamee R, Kaski JC. Total coronary occlusion in non ST elevation myocardial infarction: Time to change our practice? Int J Cardiol. Apr 15 2021;329:1-8. doi:10.1016/j.ijcard.2020.12.082
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Tue, 01 Nov 2022 - 04min - 964 - Podcast 825: ALS vs PD Transport
Contributor: Aaron Lessen, MD
Educational Pearls:
In urban settings, it is becoming more common for police to transport critical patients from scene to hospital A 2022 multicenter observational study compared mortality rates in patients with penetrating injury to torso and/or proximal extremity when transported by EMS versus police Approximately 18% of patients were transported by police Overall mortality was approximately 15% in both groups In patients with more severe injury, mortality was still similar at approximately 36% and 38% respectivelyReferences
Taghavi S, Maher Z, Goldberg AJ, et al. An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients. J Trauma Acute Care Surg. 2022;93(2):265-272. doi:10.1097/TA.0000000000003563
Jacoby SF, Branas CC, Holena DN, Kaufman EJ. Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma. Trauma Surg Acute Care Open. 2020;5(1):e000541. Published 2020 Nov 26. doi:10.1136/tsaco-2020-000541
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MS4 & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Mon, 31 Oct 2022 - 02min - 963 - Podcast 824: Catheter-Related Blood Infections
Contributor: Travis Barlock, MD
Educational Pearls:
Catheter related blood infections were thought to be caused by skin flora seeding the catheter. Thus, significant effort is applied to sterility and skin preparation. However, studies have shown that bacteria growing on the tip of the catheter is not consistent with growth on cultures of skin. Staphylococcus epidermidis is commonly found on cultures of catheter sites. It has also been found in the gut flora of >50% of ICU patients. Rates of catheter related blood infections have been decreased through oral decontamination and early feeding. These findings suggest enteral bacterial translation as a major source of blood stream infection.References
O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162-e193. doi:10.1093/cid/cir257
von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group. N Engl J Med. 2001;344(1):11-16. doi:10.1056/NEJM200101043440102
ALTEMEIER WA, HUMMEL RP, HILL EO. Staphylococcal enterocolitis following antibiotic therapy. Ann Surg. 1963;157(6):847-858. doi:10.1097/00000658-196306000-00003
Marshall JC, Christou NV, Horn R, Meakins JL. The microbiology of multiple organ failure. The proximal gastrointestinal tract as an occult reservoir of pathogens. Arch Surg. 1988;123(3):309-315. doi:10.1001/archsurg.1988.01400270043006
Mrozek N, Lautrette A, Aumeran C, et al. Bloodstream infection after positive catheter cultures: what are the risks in the intensive care unit when catheters are routinely cultured on removal?. Crit Care Med. 2011;39(6):1301-1305. doi:10.1097/CCM.0b013e3182120190
Atela I, Coll P, Rello J, et al. Serial surveillance cultures of skin and catheter hub specimens from critically ill patients with central venous catheters: molecular epidemiology of infection and implications for clinical management and research. J Clin Microbiol. 1997;35(7):1784-1790. doi:10.1128/jcm.35.7.1784-1790.1997
Tani T, Hanasawa K, Endo Y, et al. Bacterial translocation as a cause of septic shock in humans: a report of two cases. Surg Today. 1997;27(5):447-449. doi:10.1007/BF02385710
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MS4 & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Tue, 25 Oct 2022 - 03min - 962 - Podcast 823: Immediate Resuscitative ThoracotomyMon, 24 Oct 2022 - 07min
- 961 - Podcast 822: Meralgia Paresthetica
Contributor: Aaron Lessen, MD
Educational Pearls:
Lateral Cutaneous Femoral Nerve Entrapment Syndrome, also known as Meralgia Paresthetica, results from entrapment of the lateral cutaneous femoral nerve, often as it exits the pelvis under the inguinal ligament. Meralgia Paresthetica is associated with obesity, pregnancy, compression from clothing or belts and diabetes. Symptoms include numbness, paresthesia and pain of the proximal lateral thigh. Signs or symptoms of radiculopathy such as weakness, loss of reflexes or severe back pain should not be present. Diagnosis is clinical and does not require further imaging if there are no additional or concerning findings. Meralgia Paresthetica typically resolves over time without intervention; however patients should be counseled on weight loss, diabetes control and avoidance of compressive clothing as relieving factors.References
Solomons JNT, Sagir A, Yazdi C. Meralgia Paresthetica. Curr Pain Headache Rep. 2022;26(7):525-531. doi:10.1007/s11916-022-01053-7
Grossman MG, Ducey SA, Nadler SS, Levy AS. Meralgia paresthetica: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9(5):336-344. doi:10.5435/00124635-200109000-00007
Image from my.clevelandclinic.org
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Tue, 18 Oct 2022 - 03min - 960 - Podcast 821: EKGs in Syncope
Contributor: Travis Barlock, MD
Educational Pearls:
An EKG should be obtained quickly after a syncopal event to identify possible life-threatening causes such as ischemia and arrhythmia WOBBLER is a good mnemonic for remembering additional EKG findings to look for in syncope Wolff-Parkinson-White (WPW) Check for delta wave on QRS Obstructed AV node Any potential heart blocks Brugada syndrome Na channel blockade that can cause ST elevations in anterior leads Bifascicular block Conduction blockade in two of the three fascicles increases risk of complete heart block Left Ventricular Hypertrophy (LVH) Can be a sign of HOCM (younger patients) or aortic stenosis (older patients) Epsilon waves Positive deflections after the QRS that is seen in arrhythmogenic right ventricular dysplasia Repolarization abnormalities Prolonged/shortened QT segmentsReferences
Martow E, Sandhu R. When Is Syncope Arrhythmic? Med Clin North Am. 2019;103(5):793-807.
Solbiati M, Dipaola F, Villa P, et al. Predictive Accuracy of Electrocardiographic Monitoring of Patients With Syncope in the Emergency Department: The SyMoNE Multicenter Study. Acad Emerg Med. 2020;27(1):15-23.
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Mon, 17 Oct 2022 - 04min - 959 - Podcast 820: Who Qualifies for Take-Home Naloxone
Contributor: Don Stader, MD
Educational Pearls:
Home naloxone is traditionally given to those at high risk for opioid overdose such as those in the ED due to an opioid overdose, opioid intoxication, or admit to illicit opioid use There are a number of other patient populations that benefit from home naloxone including those on chronic opioid or benzodiazepine therapy, and those who report any type of illicit drug use Any illicit drug could be laced with opioids, and those who use drugs are more likely to be present as bystanders when an opioid overdose occurs Some important tips to remember when prescribing home naloxone There is often a scannable QR code that instructs bystanders on how to recognize and intervene in an overdose Inform the patient that naloxone is temporary and those who overdose are at high risk of overdosing again Provide support and inform the patient that if they decide they would like to enter treatment/rehabilitation programs, they can return to the ED to start that processReferences
Strang J, McDonald R, Campbell G, et al. Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine. Drugs. 2019;79(13):1395-1418.
Moustaqim-Barrette A, Dhillon D, Ng J, et al. Take-home naloxone programs for suspected opioid overdose in community settings: a scoping umbrella review. BMC Public Health. 2021;21(1):597.
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Tue, 11 Oct 2022 - 04min - 958 - Podcast 819: Indiscriminate Lactate Testing
Contributor: Jared Scott, MD
Educational Pearls:
Elevated lactate levels can be a useful indicator of critical illness in patients who meet SIRS criteria Lactate can also be elevated due to other causes including seizures and medications such as albuterol and metformin A recent study from Switzerland* performed routine point-of-care lactate testing in all elderly patients presenting at triage in the emergency department in order to determine the prevalence of elevated lactate in the population and its utility in predicting poor patient outcomes Patients with seizure as their chief complaint were excluded from the study due to expected transient elevated lactate levels Poor outcomes were defined as requiring extensive IVF and/orvasoactive medications, undergoing intubation, admission to the ICU, or death 27.1% of patients had an increased lactate but only 7.3% actually met poor outcome criteria ED physicians should note that an increased lactate in an elderly patient does not mean that they are critically ill Routine point-of-care lactate monitoring at triage is of limited usefulness and should instead be targeted towards those who meet critical illness criteria*Errata: This study was performed in Switzerland, not Sweden as was stated in the podcast
References
Gosselin M, Mabire C, Pasquier M, et al. Prevalence and clinical significance of point of care elevated lactate at emergency admission in older patients: a prospective study. Intern Emerg Med. 2022;17(6):1803-1812.
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Mon, 10 Oct 2022 - 05min - 957 - Podcast 818: Local Anesthetics and LAST
Contributor: Don Stader, MD
Educational Pearls:
There are two major groups of local anesthetics: Amide and Esther To recall what group an anesthetic belongs to, use this memory trick:Amide has an ‘i’ in the name and Amide anesthetics have 2 ‘i’s e.g., Lidocaine. Ester has no ‘i’ and most common Ester anesthetics have only one ‘i’ e.g., Tetracaine.
In a true allergy and/or contraindication to both local anesthetic groups, diphenhydramine is an acceptable alternative. Epinephrine is administered with local anesthetics to decrease bleeding, increase duration of action, and minimize systemic spread of the anesthetic, thus reducing toxicity. Symptoms of Local Anesthetic Systemic Toxicity (LAST) may begin with dizziness, confusion and/or slurred speech, and can progress to cardiovascular collapse and death. Treat LAST with lipid emulsion therapy i.e. ‘Intralipids’ to create a lipid sink that absorbs anesthetic agent Administer initial 1.5 ml/kg bolus (approximately 100 ml in 70 mg adult) followed by infusion rate of 0.25 mg/kg/hour. Do not surpass 10 mg/kg total.References
Dickerson DM, Apfelbaum JL. Local anesthetic systemic toxicity. Aesthet Surg J. 2014;34(7):1111-1119. doi:10.1177/1090820X14543102
Bina B, Hersh EV, Hilario M, Alvarez K, McLaughlin B. True Allergy to Amide Local Anesthetics: A Review and Case Presentation. Anesth Prog. 2018;65(2):119-123. doi:10.2344/anpr-65-03-06
Macfarlane AJR, Gitman M, Bornstein KJ, El-Boghdadly K, Weinberg G. Updates in our understanding of local anaesthetic systemic toxicity: a narrative review. Anaesthesia. 2021;76 Suppl 1:27-39. doi:10.1111/anae.15282
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visithttps://emergencymedicalminute.com/edi-award/
Tue, 04 Oct 2022 - 06min - 956 - Podcast 817: MI Risk during Elections
Contributor: Aaron Lessen, MD
Educational Pearls:
2020 retrospective study with dat from two California hospitals compared rates of cardiovascular admissions in a five day period two weeks before and the five days after the presidential election Hospitalization rate for acute cardiovascular disease increased by 17% and rate of acute myocardial infarction increased by 42% Highest rates occurred in demographic of white males older than 75 years old No significant difference between groups in rates of stroke and heart failureReferences
Mefford MT, Rana JS, Reynolds K, et al. Association of the 2020 US Presidential Election With Hospitalizations for Acute Cardiovascular Conditions. JAMA Netw Open. 2022;5(4):e228031. Published 2022 Apr 1. doi:10.1001/jamanetworkopen.2022.8031
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Mon, 03 Oct 2022 - 02min - 955 - Podcast 816: Ventilator Management in Asthmatics
Contributor: Aaron Lessen, MD
Educational Pearls:
The management of severe asthma or COPD exacerbation is complex, especially when the patient requires intubation/ventilation Asthma is an obstructive airway disease that can cause air trapping and hyperinflation of the lungs To avoid worsening hyperinflation patients typically require slower respiratory rates, lower tidal volumes, and increased expiratory time when on a ventilator Patients on a ventilator require very close monitoring to prevent worsening hyperinflation and associated complications including barotrauma and hypotension/cardiac arrest secondary to decreased venous return If patient condition starts to worsen, decrease respiratory rate and tidal volume In these cases, a decreased oxygen saturation is acceptable until their condition improves If patient status continues to worsen, consider disconnecting the ventilator and pushing on the chest for approximately 30 seconds to help force out trapped air If patient continues to decompensate, consider the possibility of a pneumothorax and determine if a chest tube is necessary Remember to continue asthma/COPD management including albuterol/duonebs, steroids, magnesium, and alternatives including as helioxReferences
Demoule A, Brochard L, Dres M, et al. How to ventilate obstructive and asthmatic patients. Intensive Care Med. 2020;46(12):2436-2449
Garner O, Ramey JS, Hanania NA. Management of Life-Threatening Asthma: Severe Asthma Series. Chest. 2022
Laher AE, Buchanan SK. Mechanically Ventilating the Severe Asthmatic. J Intensive Care Med. 2018;33(9):491-501
Summarized by Mark O’Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Tue, 27 Sep 2022 - 04min - 954 - Podcast 815: Fluid Resuscitation in Pancreatitis
Contributor: Aaron Lessen, MD
Educational Pearls:
Historically, pancreatitis has been treated with aggressive IV fluid rehydration. Recently published data shows this may not be appropriate. A randomized, controlled, multi-hospital trial evaluated outcomes for patients with acute pancreatitis receiving lactated Ringer’s solution Aggressive fluid resuscitation group received 20ml/kg bolus + 3ml/hour Moderate fluid resuscitation groups received either 10 ml/kg bolus if hypovolemic or no bolus if normovolemic. Both moderate resuscitation groups received 1.5ml/hr. The primary outcome was development of moderately severe or severe pancreatitis. 22.1% of aggressive fluid resuscitation and 17.3% of moderate fluid resuscitation patients developed primary outcome. The safety outcome was fluid overload. Fluid overload developed in 20.5% of aggressive resuscitation group and only 6.3% of moderate resuscitation group. This trial was ended early due to differences in safety outcomes without obvious difference in primary outcome Overall, aggressive fluid resuscitation had no benefit in treatment of acute pancreatitis and providers should be aware of fluid overload risk.References
de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022;387(11):989-1000. doi:10.1056/NEJMoa2202884
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Mon, 26 Sep 2022 - 03min - 953 - Podcast 814: Post-concussion Treatment
Contributor: Aaron Lessen, MD
Educational Pearls:
Recent study looked at the impact of screen time on duration of post-concussive symptoms 125 patients aged 12-25 diagnosed with a concussion were randomized to either abstain from or have unrestricted screen time for 48 hours after injury Patients with unrestricted screen time averaged approximately 5 hours/day of screen time Patients in the no screen time group averaged approximately 1 hour/day of screen time Statistically significant difference in duration of post-concussive symptoms Unrestricted screen time cohort averaged 8 days of post-concussive symptoms No screen time cohort averaged 3.5 days of post-concussive symptoms ED physicians should encourage patients to limit screen time as much as possible in the first 48 hours after a concussion to promote faster recovery from post-concussive symptomsReferences
Macnow T, Curran T, Tolliday C, et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2021;175(11):1124-1131.
Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.
Mon, 19 Sep 2022 - 02min - 952 - Podcast 813: Pulse Oximetry
Contributor: Travis Barlock, MD
Educational Pearls:
Most oxygen in the body is bound to hemoglobin, forming oxyhemoglobin. Less than 1% of the oxygen in the body is dissolved in plasma. Pulse Oximeters (Pulse Ox) function by emitting wavelengths of light from one side, and capturing the amount absorbed on the opposite side. A calculation determined the amount of saturation. Pulse Ox relies on pulsations in arterial flow to create a photoplethysmogram (pleth) for measurements Patients with poor peripheral perfusion may have unreliable pulse ox. Patient with an LVAD have constant flow and also unreliable pulse ox. Pulse Ox is a useful tool when pacing to determine mechanical capture. If there is disparity between the electrical wave pulse and the rate on pulse ox, there is likely no mechanical capture leading to poor distal flow.References
Eecen CMW, Kooter AJJ. Pulsoximeters: werking, valkuilen en praktische tips [Pulse oximetry: principles, limitations and practical applications]. Ned Tijdschr Geneeskd. 2021;165:D5891. Published 2021 May 11.
Elgendi M. On the analysis of fingertip photoplethysmogram signals. Curr Cardiol Rev. 2012;8(1):14-25. doi:10.2174/157340312801215782
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.
Tue, 13 Sep 2022 - 04min - 951 - Podcast 812: PO Medications
Contributor: Nick Tsipis, MD
Educational Pearls:
PO medications are less frequently used in the ED due to their longer onset of action The position the patient is in when given PO medications may affect how quickly the medication is absorbed The quicker the medication passes through the stomach into the small intestine, the quicker it can be absorbed and metabolized Recent study used in silico gastric biomechanics model to compare the length of time it took PO medications to pass through the stomach based on the patient’s positioning Compared the medication transit time in a stomach model placed in right lateral, left lateral, upright, and supine positions Right lateral positioning resulted in the fastest time for medication to pass through the stomach and enter the duodenum Likely due to the direction of gravity aligning with the antrum and pylorus of the stomach Left lateral positioning had the slowest time for the pill to enter the small intestine Likely due to gravity not aligning with stomach anatomy The time to absorption in the right and left lateral position were significantly faster and slower respectively than that seen in the upright and supine positions These results indicate that placing a patient in the right lateral position when giving PO medications may result in faster rate of medication onset than if the patient is in another positionReferences
Lee JH, Kuhar S, Seo JH, Pasricha PJ, Mittal R. Computational modeling of drug dissolution in the human stomach: Effects of posture and gastroparesis on drug bioavailability. Phys Fluids (1994). 2022;34(8):081904.
Summarized by Mark O’Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.
Mon, 12 Sep 2022 - 03min - 950 - Podcast 811: Ketamine for Pain
Contributor: Lessen, Aaron MD
Educational Pearls:
Ketamine can be given at 0.2-0.3 mg/kg as subdissociative doses for pain control in the ED Ketamine coadministered with Haldol may reduce agitation A recent study in Iran compared subdissociative Ketamine given with 2.5 mg Haldol to 1 mg/kg Fentanyl for pain control in the ED Ketamine with Haldol had better pain control than Fentanyl at 5, 10, 15 and 30 minutes Ketamine with Haldol less frequently required rescue medication Ketamine with Haldol did have increased agitation at only the 10 minute mark Of note, there was not a Ketamine only group to compare Ketamine with Haldol is a viable alternative combination for pain controlReferences
Moradi MM, Moradi MM, Safaie A, Baratloo A, Payandemehr P. Sub dissociative dose of ketamine with haloperidol versus fentanyl on pain reduction in patients with acute pain in the emergency department; a randomized clinical trial. Am J Emerg Med. 2022;54:165-171. doi:10.1016/j.ajem.2022.02.012
Sin B, Ternas T, Motov SM. The use of subdissociative-dose ketamine for acute pain in the emergency department. Acad Emerg Med. 2015;22(3):251-257. doi:10.1111/acem.12604
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.
Wed, 07 Sep 2022 - 03min
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