Emergency Medical Minute

By Emergency Medical Minute

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Emergency Medical Minute

Episode Date
Podcast # 480: Inhalant Abuse
04:01

Author: Sam Killian, MD

Educational Pearls:

  • Abuse occurs by breathing in volatile substances such as solvents, glues, paints, butane, and propane
  • Inhalants are generally depressants
  • Estimated that 100-125 people die every year in the US from acute inhalant abuse.
  • Short-term effects include memory impairment, slurred speech, diplopia, seizures, and cardiac arrhythmias
  • Long term effects include renal dysfunction, neuropathy, blindness and cognitive blunting
  • Evaluation includes a detailed lung exam, cardiac monitoring, and assessments of oxygenation and renal function
  • Treatment is generally supportive. 

References

Lipari RN. Understanding Adolescent Inhalant Use. 2013;. Review. PubMed PMID: 28722849.

Howard MO, Bowen SE, Garland EL, Perron BE, Vaughn MG. Inhalant use and inhalant use disorders in the United States. Addict Sci Clin Pract.2011 Jul;6(1):18-31. Review. PubMed PMID: 22003419; PubMed Central PMCID: PMC3188822.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD



Jun 19, 2019
Podcast # 479: Clots and Pregnancy
03:39

Author:  Nick Hatch, MD

Educational Pearls:

  • Pregnancy is a hypercoagulable state, which predisposes women to venous thromboembolism, but also elevates levels of circulating d-dimer
  • A recent study evaluated the YEARS protocol in combination of adjusted d-dimer cutoffs in pregnant women to evaluate for DVT and PE
  • Using this protocol, only 1 DVT was missed. No PE’s were missed.
  • This protocol has growing evidence as an option in pregnant women in whom you must rule out a DVT/PE but more validating studies are likely necessary

References

van der Pol LM, Tromeur C, Bistervels IM, Ni Ainle F, van Bemmel T, Bertoletti L, Couturaud F, van Dooren YPA, Elias A, Faber LM, Hofstee HMA, van der Hulle T, Kruip MJHA, Maignan M, Mairuhu ATA, Middeldorp S, Nijkeuter M, Roy PM, Sanchez O, Schmidt J, Ten Wolde M, Klok FA, Huisman MV. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 2019 Mar 21;380(12):1139-1149. doi: 10.1056/NEJMoa1813865. PubMed PMID: 30893534.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

 



Jun 17, 2019
Podcast # 478: Psychedelics and Depression
03:09

Author: Chris Holmes, MD

Educational Pearls:

  • Hallucinogenic drugs have been in use since ancient times for both medical and recreational purposes
  • Ayahausca is an ancient psychedelic with origins in Bolivia that causes intense vomiting followed by a psychedelic experience
  • This and other hallucinogens are gaining gaining interest for their use in depression with some startling positive initial results

References

https://www.nationalgeographic.com/culture/2019/05/ancient-hallucinogens-oldest-ayahuasca-found-shaman-pouch/

Carhart-Harris RL et. al. Psilocybin with psychological support for treatment-resistant depression: six-month follow-up. Psychopharmacology (Berl). 2018 Feb;235(2):399-408. doi: 10.1007/s00213-017-4771-x. Epub 2017 Nov 8. PubMed PMID: 29119217; PubMed Central PMCID: PMC5813086.

Palhano-Fontes F et. al. Rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression: a randomized placebo-controlled trial. Psychol Med. 2019 Mar;49(4):655-663. doi: 10.1017/S0033291718001356. Epub 2018 Jun 15. PubMed PMID: 29903051; PubMed Central PMCID: PMC6378413.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD



Jun 14, 2019
Podcast # 477: Postpolypectomy Electrocoagulation Syndrome
03:44

Author:  Nick Hatch, MD

Educational Pearls:

  • Postpolypectomy electrocoagulation syndrome (PES) is a rare complication of polypectomy and electrocautery during colonoscopy
  • Occurs when cautery causes transmural thickening from a contact burn
  • Patients can present as if they have peritonitis, with guarding, leukocytosis, fever, etc.
  • CT is the imaging of choice mainly to evaluate for bowel perforation as PES may not be seen on imaging
  • Treatment is often with antibiotics and supportive care - in severe cases, hospitalization may be required.

References

Benson BC, Myers JJ, Laczek JT. Postpolypectomy electrocoagulation syndrome: a mimicker of colonic perforation. Case Rep Emerg Med. 2013;2013:687931. doi: 10.1155/2013/687931. Epub 2013 Jul 15. PubMed PMID: 23956889; PubMed Central PMCID: PMC3728495.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD



Jun 12, 2019
Podcast # 476: Evidence for Patient Satisfaction
04:24

Author: Dylan Luyten, MD

Educational Pearls:

  • Actual wait times are weakly correlated to patient satisfaction but the difference between perceived/expected wait times and actual wait times is strongly correlated
  • Having others in the room or with the patient while they wait also has a positive effect
  • Under-promising and over-delivering can result in better patient experience
  • Managing up others and services provided also is demonstrated to improve satisfaction
  • Perceived time with health care members (physicians, APPs, nurses, etc) also is supported to improve satisfaction
  • Sitting with patients increases the perception of time

 

References

Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say?. Acad Emerg Med. 2000 Jun;7(6):695-709. Review. PubMed PMID: 10905652.

Sonis JD, Aaronson EL, Lee RY, Philpotts LL, White BA. Emergency Department Patient Experience: A Systematic Review of the Literature. J Patient Exp. 2017;5(2):101–106. doi:10.1177/2374373517731359

 

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



Jun 05, 2019
Podcast # 475: Orthostatic Vital Signs and Syncope
02:54

Author: Michael Hunt, MD

Educational Pearls:

  • A recent study evaluated the relationship between abnormal orthostatic vital signs and serious outcomes within 30 days in patients over 60 presenting to the ED with syncope
  • Of the roughly 2000 patients enrolled, about ⅓ had abnormal orthostatic vital signs
  • There was no statistically significance between orthostatic vital signs and serious outcomes in 30 days

Editor's note: study used a composite end-point of multiple serious outcomes

References

White JL, Hollander JE, Chang AM, Nishijima DK, Lin AL, Su E, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Clark CL, Diercks DB, Nicks BA, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study. Am J Emerg Med. 2019 Mar 25;. doi: 10.1016/j.ajem.2019.03.036. [Epub ahead of print] PubMed PMID: 30928476.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

 


Jun 02, 2019
Podcast # 474: Obesity Hypoventilation Syndrome
09:16

Author: Peter Bakes, MD

Educational Pearls:

  • The differential diagnosis for pedal edema includes issues in the heart, kidney, and liver
  • Obesity hypoventilation syndrome (OHS) is an important and common cause of right heart failure. Nighttime hypoventilation leads to pulmonary hypertension, causing right heart strain followed by right heart failure
  • OHS criteria includes obesity, sleep disordered breathing, and alveolar hypoventilation (PaCO2 > 45 mmHg)
  • The causes of OHS are multifactorial, and include mechanical problems with breathing and hormonal changes

References

Balachandran JS, Masa JF, Mokhlesi B. Obesity Hypoventilation Syndrome Epidemiology and Diagnosis. Sleep Med Clin. 2014;9(3):341–347. doi:10.1016/j.jsmc.2014.05.007

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



May 29, 2019
Podcast # 473: Direct to Consumer Antibiotics
03:05

Author: Sam Killian, MD

Educational Pearls:

  • A recent study in Pediatrics compared the rates of antibiotic prescriptions for acute respiratory infections (ARIs) between direct to consumer (DTC) telemedicine, urgent care, and primary care providers
  • Among the nearly 530,000 visits studied, the rate of antibiotic prescription was 52%, 42% and 31% for telemedicine, urgent care, and primary care providers, respectively
  • Nearly 4/10 antibiotic prescriptions from telemedicine visits were not indicated based on antibiotics guideline recommendations

References

Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics. 2019 May;143(5). doi: 10.1542/peds.2018-2491. Epub 2019 Apr 8. PubMed PMID: 30962253.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

May 24, 2019
Podcast # 472: SMART Crystalloids
05:44

Author: Gretchen Hinson, MD

Educational Pearls:

  • In most healthcare settings, normal saline (NS) has become ubiquitous as an intravenous fluid despite some potential drawbacks
  • Compared to normal saline, a balanced crystalloid (either lactated Ringer’s or Plasma-Lyte) was associated with a lower composite endpoint of mortality, renal replacement therapy, and renal injury in SMART (Isotonic Solutions and Major Adverse Renal Events Trial)
  • Balanced crystalloids such as lactate Ringer’s may be preferable in more critically ill populations

References

Yau YW, Kuan WS. Choice of crystalloids in sepsis: a conundrum waiting to be solved. Ann Transl Med. 2016;4(6):121. doi:10.21037/atm.2016.02.09

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 Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD




May 23, 2019
Podcast # 471: Cyclic Vomiting
04:15

Author: Don Stader, MD

Educational Pearls:

  • Cyclic vomiting syndrome (CVS) is different than cannabis hyperemesis syndrome (CHS). It is important to differentiate the two.
  • CHS is thought to be caused by activation of THC receptors in the gut
  • CVS is associated with migraines and therefore responds to similar medications
  • Olanzapine (Zyprexa) is an alternative to haloperidol (Haldol)
  • Amitriptyline, as well as anti-epileptics can be used to prevent CVS
  • Opioids worsen CVS

References

Lapoint J, Meyer S, Yu CK, Koenig KL, Lev R, Thihalolipavan S, Staats K, Kahn CA.Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline. West J Emerg Med. 2018 Mar;19(2):380-386. doi: 10.5811/westjem.2017.11.36368. Epub 2017 Nov 8. PubMed PMID: 29560069; PubMed Central PMCID: PMC5851514.

Boles RG, Lovett-Barr MR, Preston A, Li BU, Adams K. Treatment of cyclic vomiting syndrome with co-enzyme Q10 and amitriptyline, a retrospective study. BMC Neurol. 2010;10:10. Epub 2010 Jan 28.

Hikita T, Kodama H, Kaneko S, Amakata K, Ogita K, Mochizuki D, Kaga F, Nakamoto N, Fujii Y, Kikuchi A. Sumatriptan as a treatment for cyclic vomiting syndrome: a clinical trial. Cephalalgia. 2011;31(4):504. Epub 2010 Dec 8.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



May 21, 2019
Podcast # 470: Zofran and Pregnancy
03:33

Author: Jared Scott, MD

Educational Pearls:

  • Ondansetron (Zofran) is one of the latest drugs that has had concerns raised about side effects, particularly in pregnancy
  • 2018 study probed two birth defect databases to assess increases in 51 major birth defects with increased exposure to ondansetron
  • Only two of the 51 had even a modest increase, which is unclear in causation (cleft palate and renal agenesis)
  • When administering ondansetron (or any drug) to pregnant women, be able to discuss any potential risks for an informed decision by the patient

Editor's note: in this study, adjusted odds ratios for risk of birth defects from exposure to ondansetron were: cleft palate 1.6 (95% CI 1.1-2.3) and renal agenesis 1.8 (95% CI 1.1-3.0)

References

Parker SE, Van Bennekom C, Anderka M, Mitchell AA. Ondansetron for Treatment of Nausea and Vomiting of Pregnancy and the Risk of Specific Birth Defects. Obstet Gynecol. 2018 Aug;132(2):385-394. doi: 10.1097/AOG.0000000000002679. PubMed PMID: 29995744.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



May 17, 2019
Podcast # 469: Go PO
03:36

Author: Dave Rosenberg, MD

Educational Pearls:

  • Nothing by mouth (NPO) status routinely used before surgery to reduce the theoretical risk of aspiration
  • However, surgery poses a large physiological stress. Calories and fluid are needed to overcome stresses like these
  • Patients who drank 1/2 strength Gatorade up to 2 hours before surgery did better than those who did not

References

Alyssa Cheng-Cheng Zhu, Aalok Agarwala, Xiaodong Bao. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clinics in Colon and Rectal Surgery 2019; 32(02): 114-120. DOI: 10.1055/s-0038-1676476

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



May 16, 2019
Podcast # 468: Typhlitis
02:49

Educational Pearls:

  • Tiflitis refers to the presence of enterocolitis in the setting of neutropenia - also known as neutropenic enterocolitis
  • Commonly a result of chemotherapy for hematologic malignancies.
  • The infection is usually polymicrobial/fungal and can lead to septic shock
  • Usually presents with fever, abdominal pain, with associated GI complaints
  • Workup includes CBC for the ANC (usually <500), and a CT abdomen (look for bowel thickening)
  • Treatment typically with broad-spectrum antibiotics with or without anti-fungal agents
  • Mortality can be as high as 50%

References

Cloutier RL. Neutropenic enterocolitis. Emerg Med Clin North Am. 2009 Aug;27(3):415-22. doi: 10.1016/j.emc.2009.04.002. PubMed PMID: 19646645.

Rodrigues FG, Dasilva G, Wexner SD. Neutropenic enterocolitis. World J Gastroenterol.2017 Jan 7;23(1):42-47. doi: 10.3748/wjg.v23.i1.42. Review. PubMed PMID: 28104979; PubMed Central PMCID: PMC5221285.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



May 14, 2019
Podcast # 467: Cauda Equina Syndrome
02:50

Author: Erik Verzemnieks, MD

Educational Pearls:

  • Cauda equina syndrome is caused by the compression of the nerve roots that extend beyond the termination of the spinal cord
  • Trauma, infection, hematoma, disc rupture/herniation can cause this - basically anything that can cause pressure and fill space
  • Symptoms can include saddle anesthesia, lower extremity pain, numbness, incontinence, and constipation
  • Post-void residual that is abnormally high may be an indicator
  • MRI is diagnostic modality of choice
  • Emergent surgical decompression is treatment

References

Jalloh I, Minhas P. Delays in the treatment of cauda equina syndrome due to its variable clinical features in patients presenting to the emergency department. Emerg Med J. 2007 Jan;24(1):33-4. doi: 10.1136/emj.2006.038182. PubMed PMID: 17183040; PubMed Central PMCID: PMC2658150.

May 09, 2019
Podcast # 466: Subacute Sclerosing Panencephalitis
03:44

Author: Nicholas Hatch, MD

Educational Pearls:

  • Measles has a period of infectivity starts before the appearance of the characteristic rash, up to 4-5 days
  • A devastating consequence of measles is Subacute Sclerosing Panencephalitis (SSPE), which manifests 7-10 years after the initial measles infection
  • SSPE is a central nervous system disease that has no cure and is nearly universally fatal
  • Educating patients on the importance of vaccination should include discussion of these long term consequences

References

Pallivathucal LB, Noymer A. Subacute sclerosing panencephalitis mortality, United States, 1979-2016: Vaccine-induced declines in SSPE deaths. Vaccine. 2018 Aug 23;36(35):5222-5225. doi: 10.1016/j.vaccine.2018.07.030. Epub 2018 Jul 26. PubMed PMID: 30057285.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



May 06, 2019
Podcast # 465: As easy and 1, 2, 10 - Capillary Refill and Sepsis
02:30

Author: Ryan Circh, MD

Educational Pearls:

  • The 2019 ANDROMEDA-SHOCK trial compared using serum lactates to capillary refill assessment in septic shock patients to guide resuscitation
  • Capillary refill time was standardized (this is not straightforward):
    • A glass microscope slide was pressed on the ventral side of the right index finger
    • Pressure was increased until the skin was blanched
    • This pressure was sustained for another 10 seconds
    • After pressure was removed, the time to return to normal skin color was timed
    • Greater than three seconds was considered abnormal.
  • No difference between the two groups for mortality at 28-days

Editor’s note: lactates have become so ingrained in our practice it will be tough to change habits but this is an excellent quiver for those of us that hate the over reliance on this lab value alone, despite some of the limitations of the study.

References

Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654–664. doi:10.1001/jama.2019.0071

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



May 05, 2019
Podcast # 464: Narcan’t?
02:05

Author: Aaron Lessen, MD

Educational Pearls:

  • A problem of take-home-naloxone is the administration of it by an able-bodied bystander
  • Australian study looked at consecutive opioid overdose deaths in a single year to identify characteristics of overdose and potential for bystander administered naloxone
  • Of the 235 fatal heroin overdoses reviewed, 83% were alone with only 17% (38 cases) having another person present
  • Half of those in the presence of others had a bystander that was not impaired
  • Take-home-naloxone needs a competent person to administer it. Make sure to review this along with other harm reduction strategies when prescribing/dispensing it to patients

References

Stam NC, Gerostamoulos D, Smith K, Pilgrim JL, Drummer OH. Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia. Clin Toxicol (Phila). 2019 May;57(5):325-330. doi: 10.1080/15563650.2018.1529319. Epub 2018 Nov 17. PubMed PMID: 30451007.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



May 02, 2019
Podcast # 463: Buproprion Overdose
01:37

Author: Erik Verzemnieks, MD

Educational Pearls:

  • Buproprion is used as an antidepressant and for smoking cessation
  • Severe buproprion overdoses can cause seizures and lead to cardiac dysrhythmias
  • Benzodiazepines are treatment of choice for seizures
  • Bicarbonate and Interlipid are also possible treatment options with less evidence

References

Stall N, Godwin J, Juurlink D. Bupropion abuse and overdose. CMAJ. 2014 Sep 16;186(13):1015. doi: 10.1503/cmaj.131534. Epub 2014 Apr 28. PubMed PMID: 24778361; PubMed Central PMCID: PMC4162783.

Balit CR, Lynch CN, Isbister GK. Bupropion poisoning: a case series. Med J Aust. 2003 Jan 20;178(2):61-3. PubMed PMID: 12526723.

Bruccoleri RE, Burns MM. A Literature Review of the Use of Sodium Bicarbonate for the Treatment of QRS Widening. J Med Toxicol. 2016 Mar;12(1):121-9. doi: 10.1007/s13181-015-0483-y. Review. PubMed PMID: 26159649; PubMed Central PMCID: PMC4781799.

Apr 30, 2019
Podcast # 462: Death after OD
02:32

Author: Don Stader, MD

Educational Pearls:

  • 10% of patients seen in the emergency department for opioid overdose patients will die within a year
  • Half of these overdoses will occur in the next month
  • This mortality rate is higher than patients with STEMI, of which 7% will die within one year
  • Take-home naloxone, as well as medication assisted treatment like buprenorphine can save lives

References

Olfson M, Crystal S, Wall M, Wang S, Liu SM, Blanco C. Causes of Death After Nonfatal Opioid Overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-827. doi: 10.1001/jamapsychiatry.2018.1471. PubMed PMID: 29926090; PubMed Central PMCID: PMC6143082.

Olfson M, Wall M, Wang S, Crystal S, Blanco C. Risks of fatal opioid overdose during the first year following nonfatal overdose.Drug Alcohol Depend. 2018 Sep 1;190:112-119. doi: 10.1016/j.drugalcdep.2018.06.004. Epub 2018 Jul 4. PubMed PMID: 30005310.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



Apr 27, 2019
Podcast # 461: Breath Stacking
05:50

Author: Gretchen Hinson, MD

Educational Pearls:

  • Breath stacking occurs when a patient is unable to expire fully before another inspiration
  • In intubated/ventilated patients, this is because adequate time has not passed before exhalation
  • Asthmatics are susceptible due to the prolonged expiratory phase
  • Complications can include reduction in cardiac preload and cardiovascular collapse
  • Pursed-lip breathing can help in the spontaneously breathing patient
  • Intubation may be required when patients present with status asthmaticus and breath stacking

References

Phipps P, Garrard CS. The pulmonary physician in critical care . 12: Acute severe asthma in the intensive care unit. Thorax. 2003 Jan;58(1):81-8. Review. PubMed PMID: 12511728; PubMed Central PMCID: PMC1746457.

Pohlman MC, McCallister KE, Schweickert WD, Pohlman AS, Nigos CP, Krishnan JA, Charbeneau JT, Gehlbach BK, Kress JP, Hall JB. Excessive tidal volume from breath stacking during lung-protective ventilation for acute lung injury. Crit Care Med. 2008 Nov;36(11):3019-23. doi: 10.1097/CCM.0b013e31818b308b. PubMed PMID: 18824913.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



Apr 24, 2019
Podcast # 460: Hunting for PE in Syncope
02:38

Author:  Michael Hunt, MD

Educational Pearls:

 

  • Most causes of syncope are benign
  • Pulmonary embolism can result in syncope and is life threatening
  • A recent study of Canadian and US ED patients with syncope showed that 0.4% of patients had a PE at 30 day follow-up
  • PE should always be considered in cases of syncope but overall is a rare cause

 

Editor’s note: this study puts to rest a previous study from 2016 that reported a rate of PE in syncope as high as 1 in 6 in patients admitted to syncope - which was met with much skepticism based on clinical practice.

References

Roncon L, Zuin M, Casazza F, Becattini C, Bilato C, Zonzin P. Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism. Eur J Intern Med. 2018 Aug;54:27-33. doi: 10.1016/j.ejim.2018.04.004. Epub 2018 Apr 11. PubMed PMID: 29655808.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



Apr 22, 2019
Podcast # 459 Clonidine Ingestion
03:10

Author:  Julian Orenstein, MD

Educational Pearls:

 

  • Severe clonidine ingestion can present as a fluctuating mental status between typically accompanied by changes in vital signs (hypotension/bradycardia)
  • Respiratory depression requiring intubation is not uncommon

 

References

Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia and central nervous system depression, but not severe toxicity. Clin Toxicol (Phila). 2017 Mar;55(3):187-192. doi: 10.1080/15563650.2016.1277234. Epub 2017 Jan 20. PubMed PMID: 28107093.

Spiller HA, Klein-Schwartz W, Colvin JM, Villalobos D, Johnson PB, Anderson DL. Toxic clonidine ingestion in children. J Pediatr. 2005 Feb;146(2):263-6. PubMed PMID: 15689921.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



Apr 20, 2019
Podcast # 458: A Tylenol a Day Keeps the Delirium Away?
03:06

Author: Nick Hatch, MD

Educational Pearls:

 

  • A recent study investigated the effect of scheduled IV acetaminophen on the incidence of delirium in post-CABG patients in the ICU
  • The use of scheduled IV acetaminophen reduced the rate of delirium in these patients compared to placebo
  • This may be due to the analgesic effect of acetaminophen and/or less requirement on other deliriogenic medications (opiates)

 

References

Subramaniam B, Shankar P, Shaefi S, Mueller A, O'Gara B, Banner-Goodspeed V, Gallagher J, Gasangwa D, Patxot M, Packiasabapathy S, Mathur P, Eikermann M, Talmor D, Marcantonio ER. Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial. JAMA. 2019 Feb 19;321(7):686-696. doi: 10.1001/jama.2019.0234. PubMed PMID: 30778597.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD


Apr 17, 2019
Podcast # 457: Stroke Scores
04:04

Author: Jared Scott, MD

Educational Pearls:

 

  • Modified Rankin Score:  measure of disability often used to qualify outcomes following stroke  = no disability, 6=dead, 0-1 indicate good outcome)
    • 0-6 Scale
    • 0-1 indicative of good outcome
  • ASPECT score: uses CT to quantify the extent of changes in the brain due to ischemia
    • 0-10 Scale
    • 10 areas are assessed on non-contrast CT to assess for early stroke changes
    • -1 for each area with these findings
    • 8-10 is indicative of better outcomes

 

References

Aviv RI, Mandelcorn J, Chakraborty S, Gladstone D, Malham S, Tomlinson G, Fox AJ, Symons S. Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment. AJNR Am J Neuroradiol. 2007 Nov-Dec;28(10):1975-80. Epub 2007 Oct 5. PubMed PMID: 17921237.

https://manual.jointcommission.org/releases/TJC2018A/DataElem0569.html

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD


Apr 15, 2019
Podcast # 456 Hypoglycemia: Not feeling so sweet
04:13

Author: Jared Scott, MD

Educational Pearls:

 

  • Beta-blockers can mask the effects of hypoglycemia
  • Prolonged/refractory hypoglycemia should raise a suspicion for sulfonylurea (or other oral hypoglycemic) overdose
  • Interventions to reverse hypoglycemia include feeding the patient, IV dextrose, glucagon
  • Octreotide can be used as an antidote with sulfonylurea ingestion 

Editor’s note: Here is an interesting case report on using steroids for severe hypogylcemia caused by insulin overdose. Perhaps another treatment modality to keep in your back pocket?

References

Alsahli M, Gerich JE. Hypoglycemia. Endocrinol Metab Clin North Am. 2013 Dec;42(4):657-76. doi: 10.1016/j.ecl.2013.07.002. Review. PubMed PMID: 24286945.

Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.Emerg Med J. 2005 Jul;22(7):512-5. PubMed PMID: 15983093; PubMed Central PMCID: PMC1726850.

Fasano CJ, O'Malley G, Dominici P, Aguilera E, Latta DR. Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2008 Apr;51(4):400-6. Epub 2007 Aug 30. PubMed PMID: 17764782.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



Apr 12, 2019
Podcast # 455: Hunting for PeeCP
03:53

Author: Michael Hunt, MD

Educational Pearls:

 

  • Like all tests, urine toxicology (utox) screens can have false positives
  • Prescription medications such as demerol, antipsychotics, ketamine, and tramadol can all produce a false positive utox for PCP
  • Over-the-counter medication such as dextromethorphan also mimic PCP on utox

 

References

Doyon S. (January 2014). False Positive Urine Screens for Phencyclidine. ToxTidbits. Retrieved from https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2014/January%202014%20ToxTidbits.pdf

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



Apr 11, 2019
Podcast # 454: Tylenol Overdose
04:34

Educational Pearls:

 

  • Acetaminophen overdose can also present in patients taking too much over the course of days to weeks - not just intentional ingestions
  • If acute overdose is suspected, refer to the Rumak-Matthew nomogram to guide treatment based on time of ingestion and the time of level
  • In chronic overdose, Tylenol levels will not guide treatment
  • NAPQI is the toxic metabolite of acetaminophen
  • N-acetylcysteine (NAC) can be effective treatment in both acute and chronic overdoses
  • 7.5 g is the daily toxic dose of Tylenol in adults, 150mg/kg in children

 

 

References:

Smilkstein MJ. Acetaminophen. In: Goldfrank's Toxicologic Emergencies, Goldfrank LR, Flomenbaum NE, Lewin NA, et al (Eds), Appleton & Lange, Stamford 1998. P.541.

Chiew AL, Gluud C, Brok J, Buckley NA. Interventions for paracetamol (acetaminophen) overdose. Cochrane Database Syst Rev. 2018 Feb 23;2:CD003328. doi: 10.1002/14651858.CD003328.pub3. Review. PubMed PMID: 29473717.

Lancaster EM, Hiatt JR, Zarrinpar A. Acetaminophen hepatotoxicity: an updated review. Arch Toxicol. 2015 Feb;89(2):193-9. doi: 10.1007/s00204-014-1432-2. Epub 2014 Dec 24. Review. PubMed PMID: 25537186.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



Apr 09, 2019
Podcast # 453:  Headache Triggers
02:41

Author: Sam Killian, MD

Educational Pearls:

 

  • Headache is a common complaint in the ED. It’s plausible that headaches could be correlated with environmental factors
  • A 2015 study ED visits for headache found that temperature was associated with an increase visits, while higher humidity led to fewer
  • A retrospective study looking over a 10-year period for headache found that there was an increase headache presentations during days with high air pollution

 

References:

Yilmaz M, Gurger M, Atescelik M, Yildiz M, Gurbuz S. Meteorologic parameters and migraine headache: ED study. Am J Emerg Med. 2015 Mar;33(3):409-13. doi: 10.1016/j.ajem.2014.12.056. Epub 2014 Dec 31. PubMed PMID: 25601162.

Szyszkowicz M, Stieb DM, Rowe BH. Air pollution and daily ED visits for migraine and headache in Edmonton, Canada. Am J Emerg Med. 2009 May;27(4):391-6. doi: 10.1016/j.ajem.2008.03.013. PubMed PMID: 19555607.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



Apr 04, 2019
Podcast # 452: CADASIL
03:45

Author: Sam Killian, MD

Educational Pearls:

  • Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) occurs in 1:100000 individuals
  • The disease is caused by a defect in the NOTCH3 gene on chromosome 19
  • It is an important cause of stroke in young patients
  • Features include ischemia, cognitive deficits, migraines, psychiatric disease, coma, and seizure, all of which is worse with pregnancy
  • Migraine with aura is often the first presenting symptom with onset by age 30
  • Strokes typically can occur by age 50
  • Diagnosis is with MRI for characteristic lesions
  • Unfortunately there is no cure, and treatment is focused on stroke prevention with aspirin and statins

References:

Chabriat H, Joutel A, Dichgans M, Tournier-Lasserve E, Bousser MG. Cadasil. Lancet Neurol. 2009 Jul;8(7):643-53. doi: 10.1016/S1474-4422(09)70127-9. Review. PubMed PMID: 19539236.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

 

Apr 01, 2019
Podcast # 451: NSAIDs
03:39

Author: Don Stader, MD

Educational Pearls:

  • Non-steroidal anti-inflammatory drugs (NSAIDs) are effective pain relievers but come with important side effects
  • NSAIDs inhibit COX-1 and/or COX-2, which decreases the production of prostaglandins, which reduce pain and inflammation
  • Side effects of NSAIDS include increased rates myocardial infarction, stroke, and gastrointestinal bleeding, CVA
  • Effective pain reliever doses of many NSAIDs are lower than typically prescribed (i.e. ibuprofen 400 mg is as effective as 800 mg but with less risk of side effects)
  • Topical NSAIDs can be an alternative to reduce systemic effects
  • Selective Cox-2 inhibitors have less GI side effects

Editor note: What is ALTO? It’s alternative to opioids and consists of multi-modal pain control to reduce exposure to opioids. Check out more here and here.

 

References:

Derry S, Wiffen PJ, Kalso EA, Bell RF, Aldington D, Phillips T, Gaskell H, Moore RA. Topical analgesics for acute and chronic pain in adults - an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017 May 12;5:CD008609. doi: 10.1002/14651858.CD008609.pub2. Review. PubMed PMID: 28497473.

Coxib and traditional NSAID Trialists' (CNT) Collaboration., Bhala N, Emberson J, Merhi A, Abramson S, Arber N, Baron JA, Bombardier C, Cannon C, Farkouh ME, FitzGerald GA, Goss P, Halls H, Hawk E, Hawkey C, Hennekens C, Hochberg M, Holland LE, Kearney PM, Laine L, Lanas A, Lance P, Laupacis A, Oates J, Patrono C, Schnitzer TJ, Solomon S, Tugwell P, Wilson K, Wittes J, Baigent C. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013 Aug 31;382(9894):769-79. doi: 10.1016/S0140-6736(13)60900-9. Epub 2013 May 30. PubMed PMID: 23726390; PubMed Central PMCID: PMC3778977.

Kaufman DW, Kelly JP, Battista DR, Malone MK, Weinstein RB, Shiffman S. Exceeding the daily dosing limit of nonsteroidal anti-inflammatory drugs among ibuprofen users. Pharmacoepidemiol Drug Saf. 2018 Mar;27(3):322-331. doi: 10.1002/pds.4391. Epub 2018 Jan 26. PubMed PMID: 29372579.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



Mar 29, 2019
Podcast # 450: Probiotics in Gastroenteritis
02:12

Author: Sam Killian, MD

Educational Pearls:

  • Viral gastroenteritis alters the gut microbiome and it is theorized that probiotics may help reduce the duration and severity of the disease.
  • Double-blind randomized controlled trial involving almost 900 children with viral gastroenteritis compared 5 days of probiotics to a control group.
  • There was no difference in the rates of severe gastroenteritis between the two groups
  • Probiotics are likely unhelpful for kid with viral gastroenteritis

References:

Freedman SB, Williamson-Urquhart S, Farion KJ, Gouin S, Willan AR, Poonai N, Hurley K, Sherman PM, Finkelstein Y, Lee BE, Pang XL, Chui L, Schnadower D, Xie J, Gorelick M, Schuh S; PERC PROGUT Trial Group.. Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. N Engl J Med. 2018 Nov 22;379(21):2015-2026. doi: 10.1056/NEJMoa1802597. PubMed PMID: 30462939.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD



Mar 27, 2019
Podcast #449:  Banana Bags
05:42

Author: Dylan Luyten, MD

Educational Pearls:

  • A “banana bag” is a bag of IV fluid that contains various vitamins and minerals including folate and thiamine
  • IV fluids do not alter intoxicated patients recovery in the emergency department
  • Folate deficiency is rare in the intoxicated patient
  • Some intoxicated patients may be thiamine deficient, and those that would benefit the most need significantly more daily thiamine supplementation than provided in a banana bag

References:

Perez SR, Keijzers G, Steele M, Byrnes J, Scuffham PA. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patients in the emergency department: a randomised controlled trial. Emerg Med Australas. 2013 Dec;25(6):527-34. doi: 10.1111/1742-6723.12151. Epub 2013 Nov 8. PubMed PMID: 24308613; PubMed Central PMCID: PMC4253317.

Li SF, Jacob J, Feng J, Kulkarni M. Vitamin deficiencies in acutely intoxicated patients in the ED. Am J Emerg Med. 2008 Sep;26(7):792-5. doi: 10.1016/j.ajem.2007.10.003. PubMed PMID: 18774045.

ay E, Bentham PW, Callaghan R, Kuruvilla T, George S. Thiamine for prevention and treatment of Wernicke-Korsakoff Syndrome in people who abuse alcohol. Cochrane Database Syst Rev. 2013 Jul 1;(7):CD004033. doi: 10.1002/14651858.CD004033.pub3. Review. PubMed PMID: 23818100.

Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD






Mar 25, 2019
Podcast #448:  Chronic Salicylate Toxicity
02:51

Author: Ryan Circh, MD

Educational Pearls:

  • Chronic salicylate (ASA) toxicity can present in elderly patients as altered mental status
  • Consider chronic toxicity in patients with an unexplained anion gap acidosis
  • Treatment for chronic ingestion typically  includes IV fluids and urine alkalinization

References:

O'Malley GF. Emergency department management of the salicylate-poisoned patient. Emerg Med Clin North Am. 2007 May;25(2):333-46; abstract viii. Review. PubMed PMID: 17482023.

Durnas C, Cusack BJ. Salicylate intoxication in the elderly. Recognition and recommendations on how to prevent it. Drugs Aging. 1992 Jan-Feb;2(1):20-34. Review. PubMed PMID: 1554971.

Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD





Mar 23, 2019
Podcast #447:  IV Tylenol
03:06

Author: Dylan Luyten, MD

Educational Pearls:

  • Recent randomized controlled trial compared intravenous to oral acetaminophen in emergency department patients
  • There was no difference in pain relief between the groups
  • While the actual acquisition cost of these drugs are not significant, the cost multipliers that are passed onto patients lead to real dollars
  • With the significant cost of IV acetaminophen, it may not be the best choice given the lack of superiority to other formulations

References:

Furyk J, Levas D, Close B, Laspina K, Fitzpatrick M, Robinson K, Vangaveti VN, Ray R. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial.Emerg Med J. 2018 Mar;35(3):179-184. doi: 10.1136/emermed-2017-206787. Epub 2017 Dec 15. PubMed PMID: 29247042.

Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD



Mar 20, 2019
Podcast #446:  Retinal Detachment
06:29

Author: Dylan Luyten, MD

Educational Pearls:

  • 1:500 patients will experience a retinal detachment
  • Consider stroke on your differential (central retinal arterial occlusion)
  • Flashes and floaters are a common complaint with retinal detachments
  • Though patients may report fields of vision loss, visual acuity is often spared
  • Ocular ultrasound is an effective way to diagnosis retinal detachment in the ED
  • These require urgent ophthalmologic consultation for surgical repair

References:

https://www.aliem.com/2014/03/ocular-ultrasound-retinal-detachment-posterior-vitreous-detachment/

Gottlieb M, Holladay D, Peksa GD. Point-of-Care Ocular Ultrasound for the Diagnosis of Retinal Detachment: A Systematic Review and Meta-Analysis. Acad Emerg Med. 2019 Jan 13. doi: 10.1111/acem.13682. [Epub ahead of print] PubMed PMID: 30636351.

 

Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD


Mar 19, 2019
UNTAMED PART 6: Stepping Back Into Life
06:53
Mar 11, 2019
UNTAMED PART 5: Too High
27:06
Mar 11, 2019
UNTAMED PART 4: A New Perspective
24:00
Mar 11, 2019
UNTAMED PART 3: Coping With Pain
18:46
Mar 11, 2019
UNTAMED PART 2: Surviving a Medical Emergency in the Outdoors
17:13
Mar 11, 2019
UNTAMED PART 1: The Physiology of Experiencing Nature
17:29
Mar 11, 2019
Podcast #445: Hunting for the endotracheal tube
02:50

Author: Michael Hunt, MD

Educational Pearls:

  • Bedside transtracheal ultrasound to confirm proper endotracheal intubation is simple and effective
  • Review of 17 studies showed transtracheal ultrasound was was 98.7% sensitive and 97.1% specific
  • Curvilinear probe may be preferable as it provides a larger field of view

Editor’s Note: rather than explain what you’re looking for… just go here

References:

Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the Confirmation of Endotracheal Tube Intubation: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2018 Dec;72(6):627-636. doi: 10.1016/j.annemergmed.2018.06.024. Epub 2018 Aug 14. PubMed PMID: 30119943.

Summarized and edited by Erik Verzemnieks, MD


Mar 08, 2019
Podcast #444: Dyspnea in the intubated patient
02:06

Author: Aaron Lessen, MD

Educational Pearls:

  • Dyspnea can occur in up to 50% of intubated patients
  • Dyspnea is associated with prolonged mechanical intubation
  • Often goes undiagnosed as these patients have difficulty communicating
  • Expert opinion on reducing sensation of dyspnea
    • Reduce stimulation of respiratory drive like fever and acidosis
    • Give bronchodilators for patients with wheezing
    • Optimize the ventilator settings
    • Use medications for comfort (i.e. opioids, benzodiazepines)

References:

Decavèle M, Similowski T, Demoule A. Detection and management of dyspnea in mechanically ventilated patients. Curr Opin Crit Care. 2019 Feb;25(1):86-94. doi: 10.1097/MCC.0000000000000574. PubMed PMID: 30531366.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

 

Mar 06, 2019
Podcast #443: Measles - a timely revisit
03:30

Author: Sue Chilton, MD

Educational Pearls:

  • Measles is highly contagious
  • Typically patients just look sick
  • Remember 4 & 4, 14, and 4-C’s:
    • Contagious 4 days before and after onset of rash
    • 14 days for rash to appear
    • Cough, coryza, conjunctivitis (non-purulent), and Koplik’s spots
  • Under 2 and over 20 are highest risk groups
  • 1 in 1000 will die
  • Subacute sclerosing panencephalitis is one of  the most feared, degenerative, 100% fatal complications that can occur up to two decades after initial infection

Editor’s Note: Don’t be pro-plague - if you can, vaccinate your children.

References:

https://www.denverpost.com/2019/01/16/denver-measles-exposure/

Moss WJ. Measles. Lancet. 2017 Dec 2;390(10111):2490-2502. doi: 10.1016/S0140-6736(17)31463-0. Epub 2017 Jun 30. Review. PubMed PMID: 28673424.

Bester JC. Measles and Measles Vaccination: A Review. JAMA Pediatr. 2016 Dec 1;170(12):1209-1215. doi: 10.1001/jamapediatrics.2016.1787. Review. PubMed PMID: 27695849.

Summarized and edited by Erik Verzemnieks, MD

 

Mar 04, 2019
Podcast #442: When a severe man cold isn’t
04:32

Author: Jared Scott, MD

Educational Pearls:

 

  • CXR is 40-90% sensitive for detecting pneumonia when compared to CT
  • Patients with a high degree of suspicion for pneumonia may still warrant treatment despite a negative CXR

 

References:

Self WH, Courtney DM, McNaughton CD, Wunderink RG, Kline JA. High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patients: implications for diagnosing pneumonia. Am J Emerg Med. 2013 Feb;31(2):401-5. doi: 10.1016/j.ajem.2012.08.041. Epub 2012 Oct 18. PubMed PMID: 23083885; PubMed Central PMCID: PMC3556231.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Mar 02, 2019
Podcast #441: Is Heparin Worthless for ACS?
03:05

Author: Don Stader, MD

Educational Pearls:

 

  • Recent study demonstrated patients with non-STEMI treated with heparin had no difference in survival, but had an increased risk of major bleeding
  • Heparin may be an outdated medication in the era of dual anti-platelet therapy and PCI
  • Heparin may fall to the wayside like other former treatments for ACS such as morphine, oxygen and nitroglycerin as far as mortality benefit

 

References:

Chen JY, He PC, Liu YH, Wei XB, Jiang L, Guo W, Duan CY, Guo YS, Yu XP, Li J, Li WS, Zhou YL, Lin CY, Luo JF, Yu DQ, Chen ZJ, Chen W, Chen YY, Guo ZQ, Geng QS, Tan N. Association of Parenteral Anticoagulation Therapy With Outcomes in Chinese Patients Undergoing Percutaneous Coronary Intervention for Non-ST-Segment Elevation Acute Coronary Syndrome. JAMA Intern Med. 2019 Feb 1;179(2):186-194. doi: 10.1001/jamainternmed.2018.5953. PubMed PMID: 30592483

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Feb 27, 2019
Podcast # 440 : Carbon Monoxide Poisoning
04:44

Author: Katie Sprinkle, MD

Educational Pearl:

 

  • Carbon monoxide (CO) is the leading cause of death from poison world-wide
  • CO forms from the combustion of any carbon based product
  • Patients often present with non specific symptom like headache, vomiting, and malaise
  • Consider this diagnosis with multiple people presenting with similar symptoms from a single location
  • Treatment is with high flow oxygen (i.e. non-rebreather)
  • Hyperbaric therapy is controversial and up for debate - discussion with local consultants may help guide this management/transfer
  • Tobacco smokers typically have elevated levels of carbon monoxide at baseline

 

Editor’s Note: smoking hookah for one hour may be the equivalent of smoking nearly 100 cigarettes

References:

Jacob P, Abu Raddaha AH, Dempsey D, et al. Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe. Cancer Epidemiol Biomarkers Prev. 2011;20(11):2345-53.

Ng PC, Long B, Koyfman A. Clinical chameleons: an emergency medicine focused review of carbon monoxide poisoning. Intern Emerg Med. 2018 Mar;13(2):223-229. doi: 10.1007/s11739-018-1798-x. Epub 2018 Feb 12. Review. Erratum in: Intern Emerg Med. 2018 Mar 22;:. PubMed PMID: 29435715.

American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Carbon Monoxide Poisoning:., Wolf SJ, Maloney GE, Shih RD, Shy BD, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning. Ann Emerg Med. 2017 Jan;69(1):98-107.e6. doi: 10.1016/j.annemergmed.2016.11.003. PubMed PMID: 27993310.

Guzman JA. Carbon monoxide poisoning. Crit Care Clin. 2012 Oct;28(4):537-48. doi: 10.1016/j.ccc.2012.07.007. Review. PubMed PMID: 22998990.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Feb 25, 2019
Podcast # 438 : tPA for Frostbite
02:52

Author: Aaron Lessen, MD

Educational Pearls:

 

  • Several studies have shown administration of tPA can improve outcomes and reduce need for amputation
  • tPA is considered in grade III and IV frostbite
  • tPA cannot be given until after the warming process
  • Administration is systemically, not catheter directed or intra-arterial

References:

Jones LM, Coffey RA, Natwa MP, Bailey JK. The use of intravenous tPA for the treatment of severe frostbite. Burns. 2017 Aug;43(5):1088-1096. doi: 10.1016/j.burns.2017.01.013. Epub 2017 Jan 31. PubMed PMID: 28159151.

Wexler A, Zavala S. The Use of Thrombolytic Therapy in the Treatment of Frostbite Injury. J Burn Care Res. 2017 Sep/Oct;38(5):e877-e881. doi: 10.1097/BCR.0000000000000512. PubMed PMID: 28296671.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Feb 22, 2019
Podcast # 439 : Oops I did it again
02:26

Author: Aaron Lessen, MD

Educational Pearl:

  • A double ingestion of a single pill is typically a benign event but several drug classes may cause problems
  • A published review of 10 years of single medication double dose ingestion found 12 out of 876 cases had adverse events. The drugs and events were:
    • Propafenone ingestion leading to ventricular tachycardia
    • Beta blocker ingestion leading to bradycardia and hypotension
    • Calcium channel blocker leading to bradycardia and hypotension
    • Bupropion ingestion leading to seizures
    • Tramadol ingestion leading to ventricular tachycardia

Editor’s Note:

References:

Correia MS, Whitehead E, Cantrell FL, Lasoff DR, Minns AB. A 10-year review of single medication double-dose ingestions in the nation's largest poison control system. Clin Toxicol (Phila). 2019 Jan;57(1):31-35. doi: 10.1080/15563650.2018.1493205. Epub 2018 Nov 28. PubMed PMID: 30484705.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD


Feb 22, 2019
Podcast # 437 : Myasthenia Gravis
07:29

 

Podcast # 437 : Myasthenia Gravis

Author: Gretchen Hinson, MD

Educational Pearls:

  • Myasthenia gravis (MG) is an antibody mediated autoimmune disorder against the acetylcholine receptors at the neuromuscular junctions.
  • Bimodal age distribution (20’s-30’s: women; 60’s-70’s: men)
  • Presents with fluctuating muscle weakness typically worse at the end of the day with upper extremities affected more than lower and typically involving facial muscles.
  • Myasthenia crisis occurs when muscle fatigue begins to cause respiratory depression
  • MG was historically diagnosed with the Tensilon test but now often by EMG
  • Treatment of MG crisis involves plasma exchange and IVIG. Those in crisis often require intubation and ICU admission

References:

Gilhus NE. Myasthenia Gravis. N Engl J Med. 2016 Dec 29;375(26):2570-2581. doi: 10.1056/NEJMra1602678. Review. PubMed PMID: 28029925.

Roper J, Fleming ME, Long B, Koyfman A. Myasthenia Gravis and Crisis: Evaluation and Management in the Emergency Department. J Emerg Med. 2017 Dec;53(6):843-853. doi: 10.1016/j.jemermed.2017.06.009. Epub 2017 Sep 12. PubMed PMID: 28916122.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD




Feb 20, 2019
Podcast # 436 : Epinephrine Autoinjectors
02:59

Author: Charleen Gnisci, PharmD

Educational Pearls:

 

  • Between 2011 to 2016, Mylan increased EpiPen prices by 400% ($700 for 2 packs)
  • AUVI-Q was recalled in 2012, which left the market share to the EpiPen until recently
  • Teva announced last year it will be making a generic version of the EpiPen retailing around $300 but expected to decrease

 

References:

Kaplan, S. F.D.A. Approves Generic EpiPen That May Be Cheaper. The New York Times, The New York Times, 2018. Retrived from www.nytimes.com/2018/08/16/health/epipen-generic-drug-prices.html.

Tirrell, M.  FDA approves Teva's generic EpiPen after yearslong delay. 2018. Retrieved from https://www.cnbc.com/2018/08/16/fda-approves-tevas-generic-epipen-after-years-long-delay.html

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Feb 18, 2019
Podcast # 435 : UCL Injury
02:46

Author: Ryan Circh, MD

Educational Pearls:

  • Ulnar collateral ligament injury is often called gamekeeper’s thumb or skier’s thumb
  • Can results from traumatic deviating the thumb radially (abduction)
  • Poor rabbits
  • Have a low threshold for referral to hand surgery for follow up - treatment for minor injuries can be conservative but more severe require surgery to preserve function
  • This injury should be placed in a thumb spica splint
  • Radiographs are often negative unless an avulsion fracture is present

Editor’s note: to test for UCL injuries, I like this.

References:

Schroeder NS, Goldfarb CA. Thumb ulnar collateral and radial collateral ligament injuries. Clin Sports Med. 2015 Jan;34(1):117-26. doi: 10.1016/j.csm.2014.09.004. Epub 2014 Oct 11. Review. PubMed PMID: 25455399.

Madan SS, Pai DR, Kaur A, Dixit R. Injury to ulnar collateral ligament of thumb. Orthop Surg. 2014 Feb;6(1):1-7. doi: 10.1111/os.12084. Review. PubMed PMID: 24590986.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Feb 15, 2019
Podcast # 434 : TIA
05:38

Author: Peter Bakes, MD

Educational Pearl:

 

  • Transient ischemic attack (TIA) is defined as neurologic symptoms that resolve in 24 hours with no new changes on head imaging
  • Mimics include complex migraine, carotid dissection, seizure (Todd’s paralysis)
  • Typical presentation is with sudden onset of negative symptoms such as numbness, weakness, etc. 
  • Mimics tend to have positive symptoms such as photophobia, pain, etc.

 

References:

Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160.

Simmons B, et al. Transient Ischemic Attack: Part I. Diagnosis and Evaluation. American Family Physician 2012; 86(6):521-526.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Feb 13, 2019
Podcast # 433: Geriatric Ketamine
02:22

Author: Michael Hunt, MD

Educational Pearls:

  • Recent study compared ketamine to morphine in elderly patient
  • Ketamine (IV dose 0.3 mg /kg) provided equivalent pain control to morphine  (IV dose 0.1 mg / kg)
  • However, etamine group had much higher rate of side effects, including psychoperceptual
  • A lower does of 0.1 mg / kg given intravenously over 15 minutes might be a better option to start in the elderly population - you can always add more! 

References

Motov S, Mann S, Drapkin J, Butt M, Likourezos A, Yetter E, Brady J, Rothberger N, Gohel A, Flom P, Mai M, Fromm C, Marshall J. Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. Am J Emerg Med. 2019 Feb;37(2):220-227. doi: 10.1016/j.ajem.2018.05.030. Epub 2018 May 16. PubMed PMID: 29807629.

 Summarized and edited by Erik Verzemnieks, MD



Feb 09, 2019
Podcast # 432: Hunting for UTIs
03:45

Author: Michael Hunt, MD

Educational Pearls:

  • As many as 20% of women in assisted living have asymptomatic bacteriuria
  • This can present a diagnostic conundrum when seeing these patients in the emergency department, particularly for altered mental status and deciding whether to treat
  • True diagnosis of UTI in the emergency department is difficult as true diagnoses required culture results and repeated positive samples
  • Procalcitonin is an emerging biomarker that may be helpful in determining the presence of infection

References:

Cortes-Penfield NW, Trautner BW, Jump RLP. Urinary Tract Infection and Asymptomatic Bacteriuria in Older Adults. Infect Dis Clin North Am. 2017 Dec;31(4):673-688. doi: 10.1016/j.idc.2017.07.002. Review. PubMed PMID: 29079155; PubMed Central PMCID: PMC5802407.

Huang DT, Angus DC, Chang CH, Doi Y, Fine MJ, Kellum JA, Peck-Palmer OM, Pike F, Weissfeld LA, Yabes J, Yealy DM; ProACT Investigators.. Design and rationale of the Procalcitonin Antibiotic Consensus Trial (ProACT), a multicenter randomized trial of procalcitonin antibiotic guidance in lower respiratory tract infection. BMC Emerg Med. 2017 Aug 29;17(1):25. doi: 10.1186/s12873-017-0138-1. PubMed PMID: 28851296; PubMed Central PMCID: PMC5576372.

Summarized by Erik Verzemnieks, MD



Feb 07, 2019
Podcast # 431: Medication Errors
03:12

Author: Rachel Brady, MD

Educational Pearls:

  • Medication errors are estimated to be the 3rd leading cause of death
  • A 2016 study estimated 250,000 errors occur per year, with 7000-9000 leading to death
  • About 50% are in the ordering/prescribing phase; 25-30% during administration phase.
  • Overworked and distracted providers are the most common underlying reasons for medication error
  • A 2017 study found 40% of ED nurses witnessed a medication error in the last year

Editor’s Note:  This is a reasonable counterpoint

References

Farag A, Blegen M, Gedney-Lose A, Lose D, Perkhounkova Y. Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. J Emerg Nurs. 2017 May;43(3):246-254. doi: 10.1016/j.jen.2016.10.015. Epub 2017 Mar 28. PubMed PMID: 28359712.

Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139. PubMed PMID: 27143499.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD




Feb 04, 2019
Podcast # 430: Humeral IO
03:17

 Author: Aaron Lessen, MD

Educational Pearls:

  • Choose the longest needle for the humeral IO
  • Internally rotate and adduct the patients hand (resting on umbilicus) for best access to the site
  • Aim 1 cm superior to the greater tuberosity of the humerus with the needle angled 45 degrees inferiorly
  • Maintaining the line is critical - keep arm internally rotated with sling, tape or whatever works

 

 

References

Kovar J, Gillum L. Alternate route: the humerus bone - a viable option for IO access. JEMS. 2010 Aug;35(8):52-9. doi: 10.1016/S0197-2510(10)70207-2. PubMed PMID: 20708143.

http://epmonthly.com/article/get-humeral-io-access/

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

 

 



Jan 30, 2019
Podcast # 429: Oldschool Syphilis Treatment
04:11

Author: Chris Holmes, MD

Educational Pearls:

  • In WWI, the 2nd leading cause of soldier disability were STDs.
  • An early treatment of syphilis included topical and inhaled mercury
  • Bloodletting, vitriol, arsenic, and bismuth were other  treatments for syphilis.
  • Infecting patients with Malaria and treating the Malaria was also tried
  • Thankfully penicillin was discovered for our syphilis woes

References

Frith J. . Syphilis – Its early history and Treatment until Penicillin and the Debate on its Origins. Journal of Military and Veterans Health. 2012. 20(4): 49-58 https://jmvh.org/article/syphilis-its-early-history-and-treatment-until-penicillin-and-the-debate-on-its-origins/

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD


Jan 28, 2019
Podcast # 428: Severe Hypothyroidism
03:29

Author: Gretchen Hinson, MD

Educational Pearls:

  • Clinical manifestations of severe hypothyroidism may include:
    • Pale, cool, diaphoretic skin
    • Myxedema is the non-pitting edema seen in hypothyroidism
    • Hypothermia, heart failure, hypotension and shock
    • Shortness of breath
    • Cholestasis, constipation
    • Encephalopathy and coma

 

Mortality is 30-50%

Specific treatment includes thyroid hormone (T3, T4, or both) and glucocorticoids (for potential adrenal insufficiency)

 

References:

Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. 2007 Jul-Aug;22(4):224-31. Review. PubMed PMID: 17712058.

Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan. J Epidemiol. 2017 Mar;27(3):117-122. doi: 10.1016/j.je.2016.04.002. Epub 2017 Jan 5. PubMed PMID: 28142035; PubMed Central PMCID: PMC5350620.

Lee CH, Wira CR. Severe angioedema in myxedema coma: a difficult airway in a rare endocrine emergency. Am J Emerg Med. 2009 Oct;27(8):1021.e1-2. doi: 10.1016/j.ajem.2008.12.027. PubMed PMID: 19857436.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Jan 27, 2019
Podcast # 427: Cookie Dough is Delicious
02:11

 Author: Eric Miller, MD

Educational Pearls:

 

  • Recent CDC statement warms against consumption of cookie dough
  • Two common ingredients can pose risk: eggs and flour
  • Flour in dough is a raw agricultural product not treated to kill E. coli
  • A 2016 E. coli outbreak was linked to flour

 

References:

https://www.cdc.gov/features/no-raw-dough/index.html

https://www.cdc.gov/ecoli/2016/o121-06-16/index.html

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Jan 24, 2019
Podcast # 426: Ho Ho - Oh No!
02:42

Author: Katrina Iverson, MD

Educational Pearls: 

  • The winter holiday months present a unique picture of patient presentations to the emergency department
    • Some of the unique presentations include:
    • Children falling off Santa’s lap
    • Sledding injuries
    • Falling off ladders
    • Lacerations, ingestion, and insertion of broken ornaments (pediatrics)
  • Parents tend to hurt themselves on their children’s toys


References:

Lauche R, et al. (2018). ‘Santa baby, hurry [extra carefully] down the chimney tonight’ – Prevalence of Christmas related injuries 2007–2016 in the United States: Observational study. Advances in Integrative Medicine. https://doi.org/10.1016/j.aimed.2018.11.004

https://areyouawellbeing.texashealth.org/common-winter-injuries/

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

 

Jan 22, 2019
Podcast # 425: Oseltamivir Efficacy in Children
03:01

Author: Aaron Lessen, MD

Educational Pearls:

  • Recent meta-analysis reviewed efficacy oseltamivir (Tamiflu) in pediatric populations treated for influenza, showing an 18 hour reduction in duration of illness for those with laboratory confirmed influenza
  • Those with suspected influenza unsurprisingly had less effect
  • Subgroup analysis showed most benefit in those treated within the first 24 hours of symptom onset
  • Patients with confirmed influenza treated with oseltamivir had a 34% reduction in risk of otitis media

Editor’s note:  Vomiting was higher in the treatment groups; There were no significantly different outcomes in regards to other endpoints, such as lower respiratory tract infections and hospitalizations

References:

Malosh RE, Martin ET, Heikkinen T, Brooks WA, Whitley RJ, Monto AS. Efficacy and Safety of Oseltamivir in Children: Systematic Review and Individual Patient Data Meta-analysis of Randomized Controlled Trials. Clin Infect Dis. 2018 May 2;66(10):1492-1500. doi: 10.1093/cid/cix1040. PubMed PMID: 29186364.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD


Jan 18, 2019
Podcast # 424: Hunting for Measles
04:24

Author: Mike Hunt, MD

Educational Pearls:

  • Measles is highly contagious and successfully infects 90% of those at risk exposed to the virus.
  • 10 day prodrome where patients are asymptomatic.
  • 3 day period of characteristic cough, coryza, conjunctivitis, fever and Koplick spots with a maculopapular rash that moves from head through trunk
  • Infection risk extends three to four days after the onset of rash but also three to four days prior to onset.  Have fun with that.
  • A potential exposure, say in an emergency department waiting room, needs review of any exposed patient’s immunization history to contain spread

References:

Moss WJ. Measles. Lancet. 2017 Dec 2;390(10111):2490-2502. doi: 10.1016/S0140-6736(17)31463-0. Epub 2017 Jun 30. Review. PubMed PMID: 28673424.

Bester JC. Measles and Measles Vaccination: A Review. JAMA Pediatr. 2016 Dec 1;170(12):1209-1215. doi: 10.1001/jamapediatrics.2016.1787. Review. PubMed PMID: 27695849.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Jan 16, 2019
Podcast # 423: Blunt Cardiac Injuries
04:01

Author: Mike Hunt, MD

Educational Pearls:

 

  • Blunt cardiac injuries most commonly occur in motor vehicle collisions, auto-pedestrian collisions, and from sports injuries
  • The more anterior right ventricle is the most commonly injured structure
  • Look for new EKG changes such as bundle branch blocks, ST changes, or other arrhythmias
  • New EKG abnormalities should prompt consideration of further workup and admission for telemetry
  • Patients may have an elevated troponin - but it is unclear when exactly this should be drawn after the injury

 

References:

Bellister SA, Dennis BM, Guillamondegui OD. Blunt and Penetrating Cardiac Trauma. Surg Clin North Am. 2017 Oct;97(5):1065-1076. doi: 10.1016/j.suc.2017.06.012. Review. PubMed PMID: 28958358.

Marcolini EG, Keegan J. Blunt Cardiac Injury. Emerg Med Clin North Am. 2015 Aug;33(3):519-27. doi: 10.1016/j.emc.2015.04.003. Epub 2015 Jun 10. Review. PubMed PMID: 26226863.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Jan 14, 2019
Podcast # 422: ED Opioid Prescription Trends
04:36

Author: Jared Scott, MD

Educational Pearls:

 

  • From 1996 to 2012, the total quantity of opioids prescribed increased 647% for non-cancer pain
  • Office based prescriptions accounted for 84% of the total opioid prescriptions, up from 64%
  • The total share of opioids prescribed from the emergency department declined from 10% to 3.9% but
  • Total opioids prescribed from the ED still increased 219% over this same time frame

 

References:

Axeen S, Seabury SA, Menchine M. Emergency Department Contribution to the Prescription Opioid Epidemic. Ann Emerg Med. 2018 Jun;71(6):659-667.e3. doi: 10.1016/j.annemergmed.2017.12.007. Epub 2018 Jan 16. PubMed PMID: 29373155

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Jan 11, 2019
Podcast # 421: Sweet DKA Pearls
04:09

Author: Gretchen Hinson, MD

Educational Pearls:

 

  • Diabetic ketoacidosis patients are subject to electrolyte derangements
  • Potassium should be monitored closely:
    • K < 3.3 = Do not give insulin and replete K first
    • 3.3 < K < 5.3 = give 20-30mEq K for each L of IVF 
    • K > 5.3 = delay potassium replacement
  • Adult patients are typically severely volume depleted and can require 50 cc/kg bolus or more
  • Insulin typically given in bolus of 0.1 units/kg followed by drip at 0.1 units/kg/hr

 

References:

Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606. doi: 10.1016/j.mcna.2016.12.011. Review. PubMed PMID: 28372715.

Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management.Metabolism. 2016 Apr;65(4):507-21. doi: 10.1016/j.metabol.2015.12.007. Epub 2015 Dec 19. Review. PubMed PMID: 26975543.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Jan 09, 2019
Podcast # 420: CT Contrast and the Kidneys
02:14

Author: Don Stader, MD

Educational Pearls:

 

  • Recent meta-analysis has demonstrated that there is no significant risk for kidney injury from CT contrast
  • Most kidney injury  seen after contrast CTs were due to other underlying illnesses (sepsis, hypovolemia, etc.)
  • Older contrast agents likely did have nephrotoxic effects but this appears to be a thing of the past

 

References:

Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR. Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med. 2018 Jan;71(1):44-53.e4. doi: 10.1016/j.annemergmed.2017.06.041. Epub 2017 Aug 12. Review. PubMed PMID: 28811122.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Jan 07, 2019
Podcast # 419: Etripamil
03:55

Author: Don Stader, MD

Educational Pearls:

 

  • Etripamil is an intranasal calcium channel blocker in development for use in SVT
  • A recent study showed that etripamil has an SVT conversion rate of around 80%
  • Etripamil does not have the same feeling of “impending doom” that can occur with adenosine

Editor's note: Etripamil is still in development and these results are from a phase II clinical trial.

 

References:

Stambler BS, Dorian P, Sager PT, Wight D, Douville P, Potvin D, Shamszad P, Haberman RJ, Kuk RS, Lakkireddy DR, Teixeira JM, Bilchick KC, Damle RS, Bernstein RC, Lam WW, O'Neill G, Noseworthy PA, Venkatachalam KL, Coutu B, Mondésert B, Plat F. Etripamil Nasal Spray for Rapid Conversion of Supraventricular Tachycardia to Sinus Rhythm. J Am Coll Cardiol. 2018 Jul 31;72(5):489-497. doi: 10.1016/j.jacc.2018.04.082. PubMed PMID: 30049309.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD


Dec 20, 2018
Podcast # 418: Vertebral Artery Dissection
03:23

Author: Don Stader, MD

Educational Pearls:

  • Vertebral artery dissection (VAD) contributes to just 2% of strokes overall but ~25% of strokes for patients < 30
  • VAD is associated with minor trauma (chiropractic manipulation, yoga), typically with neck extension and rotation.
  • VAD can cause posterior stroke symptoms (vertigo, diplopia, Horner’s Syndrome, Wallenberg Syndrome)
  • Overall a good prognosis with around 50% of patients recovering without lasting neurologic deficits.

References:

Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009 Jul;8(7):668-78. doi: 10.1016/S1474-4422(09)70084-5. Review. PubMed PMID: 19539238.

Gottesman RF, Sharma P, Robinson KA, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012;18(5):245-54.

Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. Review. PubMed PMID: 11259724.

 

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

 

Dec 17, 2018
Podcast # 417: Water Balance
03:00

Author: Katie Sprinkle, MD

Educational Pearls:

  • Hyponatremia results when patients over hydrate and dilute their sodium with too much free water
  • Symptoms of hyponatremia can mimic symptoms of dehydration (dizziness,  lightheadedness, general malaise)
  • With severe hyponatremia patients can progress to seizure, coma, and death
  • Hypernatremia results from dehydration and is more common

References:

Bennett BL, Hew-Butler T, Hoffman MD, Rogers IR, Rosner MH; Wilderness Medical Society.. Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S30-42. doi: 10.1016/j.wem.2014.08.009. PubMed PMID: 25498260.

Braun MM, Barstow CH, Pyzocha NJ. Diagnosis and management of sodium disorders: hyponatremia and hypernatremia. Am Fam Physician. 2015 Mar 1;91(5):299-307. PubMed PMID: 25822386.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Dec 15, 2018
Podcast # 416: Wide Complex Tachycardia
03:25

Author: Aaron Lessen, MD

Educational Pearls:

  • Defined as QRS over 120 ms and rate over 120
  • Two major rhythms = Vetricular tachycardia (VT) or SVT with aberrancy
  • Safest approach is to assume it is VT
  • Synchronized Cardioversion is preferred even for stable VT for multiple reasons including safety and efficacy
  • Procainamide is preferred pharmacologic option
  • Amiodarone is less preferred third option
  • Calcium channel blockers (i.e. diltiazem) can worsen certain rhythms and should be avoided

References:

Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med. 2017 Apr;52(4):484-492. doi: 10.1016/j.jemermed.2016.09.010. Epub 2016 Oct 15. Review. PubMed PMID: 27751700.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Dec 12, 2018
Podcast # 415: Myofascial Pain Syndrome & Fibromyalgia
02:49

Author: Ryan Circh, MD

Educational Pearls:

  • Myofascial pain syndrome (MFPS) is typically unilateral with discrete points of palpable pain
  • Often secondary to repeated use and poor posture.
  • MFPS typically responds very well to trigger point injections.
  • Fibromyalgia is bilateral and diffuse and is thought to have a psychological component
  • Some of the best pharmacological treatments for fibromyalgia are Tramadol and Flexeril

References:

Tofferi JK, Jackson JL, O'Malley PG. Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Arthritis Rheum. 2004 Feb 15;51(1):9-13. PubMed PMID: 14872449.

Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17;292(19):2388-95. Review. PubMed PMID: 15547167.

Giamberardino MA, Affaitati G, Fabrizio A, Costantini R. Myofascial pain syndromes and their evaluation. Best Pract Res Clin Rheumatol. 2011 Apr;25(2):185-98. doi: 10.1016/j.berh.2011.01.002. Review. PubMed PMID: 22094195.

Borg-Stein J, Iaccarino MA. Myofascial pain syndrome treatments. Phys Med Rehabil Clin N Am. 2014 May;25(2):357-74. doi: 10.1016/j.pmr.2014.01.012. Epub 2014 Mar 17. Review. PubMed PMID: 24787338

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD


Dec 10, 2018
Podcast # 414: Acute Limb Ischemia
04:28

Author: Dylan Luyten, MD

Educational Pearls:

 

  • Symptoms of acute limb ischemia are the 5 P’s: Pulselessness, pain, pallor, paresthesias, and poikilothermia
  • Sudden onset of non-traumatic extremity pain should raise concern for this diagnosis
  • Obtaining an ankle brachial index (ABI) can help confirm the diagnosis
  • Consultation with vascular surgery should be immediately after the clinical diagnosis and before any further delays to obtain further imaging

 

References:

Santistevan JR. Acute Limb Ischemia: An Emergency Medicine Approach. Emerg Med Clin North Am. 2017 Nov;35(4):889-909. doi: 10.1016/j.emc.2017.07.006. Epub 2017 Aug 23. Review. PubMed PMID: 28987435.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD





Dec 08, 2018
Podcast # 413: Fascia Iliaca Block
06:13

Author: Katie Sprinkle, MD

Educational Pearls:

 

  • The fascia iliaca block is useful for hip and proximal femur fractures.
  • Typically involves injecting 40-60 mL of diluted bupivacaine (0.25%) under the fascia iliaca (or other anesthetic)
  • Anesthesia is achieved of the femoral, obturator, and lateral femoral cutaneous nerves.
  • Monitor for signs of bupivacaine toxicity (paresthesias, AMS, seizures, arrhythmias)
  • Intralipid can be an effective treatment for life-threatening toxicity

 

References:

Hoegberg LC, Bania TC, Lavergne V, Bailey B, Turgeon AF, Thomas SH, Morris M, Miller-Nesbitt A, Mégarbane B, Magder S, Gosselin S; Lipid Emulsion Workgroup.. Systematic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clin Toxicol (Phila). 2016 Mar;54(3):167-93. doi: 10.3109/15563650.2015.1121270. Epub 2016 Feb 6. Review. PubMed PMID: 26853119.

https://www.acepnow.com/article/control-hip-fracture-pain-without-opioids-using-ultrasound-guided-fascia-iliaca-compartment-block/?singlepage=1&theme=print-friendly

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD



Dec 06, 2018
Podcast #412: tPa Mission Creep
02:29

Author: Aaron Lessen, MD

Educational Pearls:

  • Patients with "minor" strokes with NIHSS 0 to 5  can still end up having poor long-term outcomes
  • Recent study compared use of alteplase vs. aspirin for these patients and saw no difference in regards to favorable neurologic outcome at 90 days
  • Study was ended early due to patient recruitment difficulties

Editor's note: though ended early, it is debatable whether even if appropriately powered there would have been an identifiable benefit

 

References:

Khatri P, Kleindorfer DO, Devlin T, Sawyer RN Jr, Starr M, Mejilla J, Broderick J, Chatterjee A, Jauch EC, Levine SR, Romano JG, Saver JL, Vagal A, Purdon B, Devenport J, Pavlov A, Yeatts SD; PRISMS Investigators. Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial. JAMA. 2018 Jul 10;320(2):156-166. doi: 10.1001/jama.2018.8496. PubMed PMID: 29998337.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

 

Dec 03, 2018
Podcast #411: Mass Casualty Incident
04:04

 Author: Dylan Luyten, MD

Educational Pearls:

 

  • Early recognition that the current situation is a mass casualty incident (MCI) is essential with establishing a sole provider/nurse to oversee
  • Team members labeling themselves by name and role is also helpful
  • Practice and prepare for these unfortunate events

 

Editor’s note: This podcast comes at the end of a MCI drill over several days

References:

http://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/

 

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD




Nov 30, 2018
Podcast #410: FAmbulance
02:30

Author: Aaron Lessen, MD

Educational Pearls:

  • Retrospective study looking at type of transportation and mortality outcomes for patients with penetrating trauma
  • Mortality was 2.2 % for those brought in by private vehicle compared to 11.6% by EMS

 

 

Editor’s note: the above is raw mortality - even after risk adjustments the odds ratio of death was statistically significant for penetrating injuries, which held true even over multiple trauma systems. Shout out to Dr Haut as well!

References:

Wandling MW, Nathens AB, Shapiro MB, Haut ER. Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System-Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services. JAMA Surg. 2018 Feb 1;153(2):107-113. doi: 10.1001/jamasurg.2017.3601. PubMed PMID: 28975247; PubMed Central PMCID: PMC5838586.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD


Nov 28, 2018
Podcast #409:  Acute CHF Second Liners
03:51

Author: Nick Hatch, MD

Educational Pearls:

 

  • Quick review on typical treatments for acute CHF:
    • Nitrates are a mainstay to reduce preload
    • Furosemide has fallen out of favor in regards to urgency but still essential; it can also be utilized in those with poor renal function
  • Before going into the weeds:
    • Phlebotomy can be used to remove volume and may be helpful in certain clinical scenarios
    • Trapping venous blood by using blood pressure cuffs on three of four extremities was a very early treatment of CHF

 

References:

Alzahri MS, Rohra A, Peacock WF. Nitrates as a Treatment of Acute Heart Failure. Card Fail Rev. 2016 May;2(1):51-55. doi: 10.15420/cfr.2016:3:3. PubMed PMID: 28785453; PubMed Central PMCID: PMC5490950.

Paterna S, Di Gaudio F, La Rocca V, Balistreri F, Greco M, Torres D, Lupo U, Rizzo G, di Pasquale P, Indelicato S, Cuttitta F, Butler J, Parrinello G. Hypertonic Saline in Conjunction with High-Dose Furosemide Improves Dose-Response Curves in Worsening Refractory Congestive Heart Failure. Adv Ther. 2015 Oct;32(10):971-82. doi: 10.1007/s12325-015-0254-9. Epub 2015 Oct 31. PubMed PMID: 26521190; PubMed Central PMCID: PMC4635178.

Huijskes RV, Hoogenberg K, Wiesfeld AC, Pijl ME, van Gelder IC. Phlebotomies as a treatment of serious heart failure due to haemochromatosis: a case report. Neth Heart J. 2009;17(11):438-41.

Burch, George E., and Nicholas P. DePasquale. "Congestive Heart Failure—Acute Pulmonary Edema." JAMA 208.10 (1969): 1895-1897.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD



Nov 26, 2018
Podcast #408: Go the hell to sleep
03:53

Author: Don Stader, MD

Educational Pearls:

  • Recent study showed efficacy 5mg IM midazolam > 10mg IM olanzapine > 10mg IM haloperidol for quickly sedating an agitated patient
  • If you have access, ketamine intravenous is the fastest
  • Olanzapine should be used with caution in elderly patients because of its anticholinergic properties
  • Ketamine can transiently worsen psychosis in some mental illness
  • Haloperidol is contraindicated in patients with prolonged QT
  • Olanzapine can be safely given intravenous as another option to your sedating arsenal

References:

Klein LR, Driver BE, Miner JR, Martel ML, Hessel M, Collins JD, Horton GB, Fagerstrom E, Satpathy R, Cole JB. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):374-385. doi: 10.1016/j.annemergmed.2018.04.027. Epub 2018 Jun 7. PubMed PMID: 29885904.

Chew ML, Mulsant BH, Pollock BG, Lehman ME, Greenspan A, Kirshner MA, Bies RR, Kapur S, Gharabawi G. A model of anticholinergic activity of atypical antipsychotic medications. Schizophr Res. 2006 Dec;88(1-3):63-72. Epub 2006 Aug 22. PubMed PMID: 16928430.

Mankowitz SL, Regenberg P, Kaldan J, Cole JB. Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. J Emerg Med. 2018 Nov;55(5):670-681. doi: 10.1016/j.jemermed.2018.07.017. Epub 2018 Sep 7. PubMed PMID: 30197153.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

 

 

Nov 23, 2018
Podcast #407:  Choose your own blister adventure
01:54

Author: Don Stader, MD

Educational Pearls:

 

  • Three options for a blister in partial thickness burns:  do nothing, unroof it, or poke a hole in it
  • Recent study suggest that aspirating the blister may be more effective in regards to wound healing
  • The overlying skin acts as a bio-band-aid and patients recover slightly faster

References:

Ro HS, Shin JY, Sabbagh MD, Roh SG, Chang SC, Lee NH. Effectiveness of aspiration or deroofing for blister management in patients with burns: A prospective randomized controlled trial. Medicine (Baltimore). 2018 Apr;97(17):e0563. doi: 10.1097/MD.0000000000010563. PubMed PMID: 29703044; PubMed Central PMCID: PMC5944508.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD



Nov 21, 2018
Podcast #406: PO vs. IV Tylenol
02:45

Author: Don Stader, MD

Educational Pearls:

 

  • Intravenous Tylenol currently is many times more expensive than oral
  • Single ED study comparing the two has methodology flaws and there is a lack of additional evidence to support intravenous over oral formulations solely for pain control
  • Oral Tylenol appears to be at least equally efficacious, though with a slightly slower onset of action

 

References:

Furyk J, Levas D, Close B, Laspina K, Fitzpatrick M, Robinson K, Vangaveti VN, Ray R. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial. Emerg Med J. 2018 Mar;35(3):179-184. doi: 10.1136/emermed-2017-206787. Epub 2017 Dec 15. PubMed PMID: 29247042.

Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making. Can J Hosp Pharm. 2015 May-Jun;68(3):238-47. Review. PubMed PMID: 26157186; PubMed Central PMCID: PMC4485512.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD



Nov 19, 2018
Podcast #405: Infant Walkers
22

Author: Don Stader, MD

Educational Pearls:

 

  • Recent study has revealed that infant walkers are more harmful than helpful
  • Infant walkers can also delay motor function
  • The American Academy of Pediatrics calls for a ban on walkers as they are a preventable cause of injury

 

References:

Siegel AC, Burton RV. (1999).Effects of baby walkers on motor and mental development in human infants. Journal of Developmental and Behavioral Pediatrics. 20:355–361.

Sims A, et al. (2018). Infant Walker-Related Injuries in United States. Pediatrics 142(4).

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD


Nov 16, 2018
Podcast #404: Electric Scooter Injuries
02:36

Author: Sam Killian, MD

Educational Pearls:

 

  • Recent news articles are showing an increase in injuries related to riding electric scooters
  • Year-to-year, scooter injuries have increased as high as three to four times
  • More definitive evidence still to come

Editor’s note: don’t follow birdgraveyard on instagram

References:

https://www.washingtonpost.com/business/economy/scooter-use-is-rising-in-major-cities-so-are-trips-to-the-emergency-room/2018/09/06/53d6a8d4-abd6-11e8-a8d7-0f63ab8b1370_story.html?noredirect=on&utm_term=.a6e46ff35bdc

https://kutv.com/news/local/er-doctors-report-161-increase-in-scooter-injuries-in-downtown-salt-lake-city

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD



Nov 14, 2018
Podcast #403: Meniscus Lock
03:34

Author: Mark Hinton, MD

Educational Pearls:

 

  • Meniscus lock can occur with a tear leading to inability to extend the knee
  • Treatment can include an intra-articular joint block followed by straightening
  • Medial meniscus injuries are more common

 

References:

Allum RL, Jones JR. The locked knee. Injury. 1986 Jul;17(4):256-8. PubMed PMID: 3770920.

Critchley IJ, Bracey DJ. The acutely locked knee--is a manipulation worth while? Injury. 1985 Jan;16(4):281-3. PubMed PMID: 3967919.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD



Nov 12, 2018
Podcast #402: Rapid sequence intubation medications
04:08

Educational Pearls:

  • RSI includes induction agent (sedative) and a paralytic
  • Succinylcholine is a depolarizing paralytic of rapid onset and short duration with contraindications in hyperkalemic states and muscular dystrophy
  • Rocuronium and vecuronium are longer acting, non-depolarizing paralytic, more commonly
  • Common induction agents are etomidate and ketamine
  • Ketamine can be particularly beneficial for bronchodilator effects in those with reactive airway disease

References:

 

Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother. 2014 Jan;48(1):62-76. doi: 10.1177/1060028013510488. Epub 2013 Nov 4. Review. PubMed PMID: 24259635.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

Nov 09, 2018
Podcast #401: Foreign Body Aspiration
06:05

Author: Gretchen Hinson, MD

Educational Pearls:

  • Diagnosis can be difficult and often delayed
  • Asymmetric breath sounds, choking, stridor may be present, but children also present asymptomatically
  • Peak incidence around one to two years of age
  • Hot dogs, nuts, popcorn – round and smooth objects are most commonly aspirated

References:

Green SS. Ingested and Aspirated Foreign Bodies. Pediatr Rev. 2015 Oct;36(10):430-6. doi: 10.1542/pir.36-10-430. Review. PubMed PMID: 26430203.

Sink JR, Kitsko DJ, Georg MW, Winger DG, Simons JP. Predictors of Foreign Body Aspiration in Children. Otolaryngol Head Neck Surg. 2016 Sep;155(3):501-7. doi: 10.1177/0194599816644410. Epub 2016 Apr 12. PubMed PMID: 27071446.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD



Nov 06, 2018
Podcast #400: ECMO
06:05

Author: Dylan Luyten, MD

Educational Pearls:

 

  • Extracorporeal membrane oxygenation (ECMO) is similar to bypass
  • ECMO is being utilized routinely at some centers and even prehospital in cardiac arrest
  • There are two general types of ECMO:
    • Venovenous (VV-ECMO) is useful when the patient cannot oxygenate but has adequate heart function.
    • Venoarterial (VA-ECMO) is more like typical bypass and can be used in a pulseless patient

 

References:

Ouweneel DM, Schotborgh JV, Limpens J, Sjauw KD, Engström AE, Lagrand WK, Cherpanath TGV, Driessen AHG, de Mol BAJM, Henriques JPS. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med. 2016 Dec;42(12):1922-1934. doi: 10.1007/s00134-016-4536-8. Epub 2016 Sep 19. Review. PubMed PMID: 27647331; PubMed Central PMCID: PMC5106498.

Tonna JE, Johnson NJ, Greenwood J, Gaieski DF, Shinar Z, Bellezo JM, Becker L, Shah AP, Youngquist ST, Mallin MP, Fair JF 3rd, Gunnerson KJ, Weng C, McKellar S; Extracorporeal REsuscitation ConsorTium (ERECT) Research Group.. Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO). Resuscitation. 2016 Oct;107:38-46. doi: 10.1016/j.resuscitation.2016.07.237. Epub 2016 Aug 11. PubMed PMID: 27523953; PubMed Central PMCID: PMC5475402.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD







Nov 02, 2018
Podcast #399: Hunting for pancreatitis
03:35

Author: Michael Hunt, MD

Educational Pearls:

  • Alcohol and gallstones are most common causes of pancreatitis
  • Diagnosis is not simply based on lipase alone - must have at least two the the three criteria:
    • Elevated lipase (greater than 3x upper limit of reference range)
    • Typical pain (epigastric pain, radiating to back, etc.)
    • Radiographic findings suggestive of pancreatitis (CT, MRI, US)
  • BISAP criteria can help risk stratify mortality in pancreatitis. You get 1 point for each of the following:
    • BNP > 25
    • Impaired mental status
    • SIRS criteria, more than 2
    • AGE > 60
    • Pleural effusion
  • BISAP score of 0 has < 1% mortality

Editor’s note: The severity of pancreatitis does not correlate with serum lipase levels - notice how it is not used in the BISAP criteria, as an example. Even a mild elevation in serum testing can result in severe pancreatitis.

References:

Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis Classification Working Group.. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25. PubMed PMID: 23100216.

Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A, Whitcomb DC. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol. 2010 Feb;105(2):435-41; quiz 442. doi: 10.1038/ajg.2009.622. Epub 2009 Oct 27. PubMed PMID: 19861954.

Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698-703. doi: 10.1136/gut.2008.152702. Epub 2008 Jun 2. PubMed PMID: 18519429.



Oct 31, 2018
Podcast #398: Who is gonna fail your antibiotic plan?
01:55

Author: Erik Verzemnieks, MD

Educational Pearls:

  • Recent study provides at least some evidence to help predict antibiotic failure for cellulitis, which is not necessarily straight forward
  • Intuitive risk factors such as recent cellulitis, chronic ulcers, history of MRSA are associated with antibiotic treatment failure
  • Oddly, tachypnea at triage was associated with the highest odds ratio for treatment failure

References:

Yadav K, Suh KN, Eagles D, MacIsaac J, Ritchie D, Bernick J, Thiruganasambandamoorthy V, Wells G, Stiell IG. Predictors of Oral Antibiotic Treatment Failure for Nonpurulent Skin and Soft Tissue Infections in the Emergency Department. Acad Emerg Med. 2018 Jun 5. doi: 10.1111/acem.13492.

Summarized and edited by Erik Verzemnieks, MD

 

 

Oct 29, 2018
Podcast #397: Oh… Pharyngeal Trauma
03:14

Author: Aaron Lessen, MD

Educational Pearls:

 

  • Injuries from penetrating pharyngeal trauma  are often subtle on examination in children
  • Potentially serious complications including carotid artery injury, mediastinitis from spreading infection, or airway compromise from hematoma formation
  • Imaging choice is typically CTA to assess for vascular injuries
  • These injuries may require antibiotics

 

References:

 

Zonfrillo MR, Roy AD, Walsh SA. Management of pediatric penetrating oropharyngeal trauma. Pediatr Emerg Care. 2008 Mar;24(3):172-5. doi: 10.1097/PEC.0b013e3181669072. PubMed PMID: 18347498.

Sasaki T, Toriumi S, Asakage T, Kaga K, Yamaguchi D, Yahagi N. The toothbrush: a rare but potentially life-threatening cause of penetrating oropharyngeal trauma in children. Pediatrics. 2006 Oct;118(4):e1284-6. PubMed PMID: 17015515.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD



Oct 27, 2018
Podcast #396: Oncologic Emergencies
04:29

Author: Rachel Brady, MD

Educational Pearls:

Hypercalcemia of malignancy:

  • Hypercalcemia of malignancy can present with lethargy, muscle weakness, hyperreflexia, altered mental status, cardiac dysrhythmias, and even cardiac arrest.
  • Treatment is based both on calcium level and symptoms
  • Intravenous rehydration is first line treatment
  • Other options include steroids, bisphosphonates and calcitonin. 

Tumor Lysis Syndrome

  • Occurs due to the breakdown of tumor cells after chemotherapy/radiation
  • Presents as hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia
  • Treatment is very similar to severe hypercalcemia - hydration with crystalloids
  • Hyperuricemia can be treated using rasburicase or allopurinol

 

References:

Ñamendys-Silva SA, Arredondo-Armenta JM, Plata-Menchaca EP, Guevara-García H, García-Guillén FJ, Rivero-Sigarroa E, Herrera-Gómez A. Tumor lysis syndrome in the emergency department: challenges and solutions. Open Access Emerg Med. 2015 Aug 20;7:39-44. doi: 10.2147/OAEM.S73684. eCollection 2015. Review. PubMed PMID: 27147889; PubMed Central PMCID: PMC4806807.

Zagzag J, Hu MI, Fisher SB, Perrier ND. Hypercalcemia and cancer: Differential diagnosis and treatment. CA Cancer J Clin. 2018 Sep;68(5):377-386. doi: 10.3322/caac.21489. Epub 2018 Sep 21. Review. PubMed PMID: 30240520.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD



 

Oct 24, 2018
Podcast #395: Aspirin for everyone!
02:33

Author: Aaron Lessen, MD

Educational Pearls:

 

  • In patients without indications for aspirin, three recent studies looked at prevention of several end points in the elderly
  • These showed no benefit in preventing cardiovascular events (stroke, MI, hear failure), disability, or death in elderly
  • These studies also demonstrated higher mortality and increased bleeding risk in patients who were taking aspirin without clear indications

Editor's note: the increased all cause mortality is intriguing - but attributed to an increase in cancer mortality. Unclear why but will be important to see if this trend is seen in other studies.

 

References:

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1499-1508. doi: 10.1056/NEJMoa1800722. Epub 2018 Sep 16. PubMed PMID: 30221596.

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1509-1518. doi: 10.1056/NEJMoa1805819. Epub 2018 Sep 16. PubMed PMID: 30221597.

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1519-1528. doi: 10.1056/NEJMoa1803955. Epub 2018 Sep 16. PubMed PMID: 30221595.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD



Oct 22, 2018
Podcast #394: Myths of Medication Assisted Treatment
05:51

Author: Katie Sprinkle, MD

Educational Pearls:

  • Medication Assisted Treatment (MAT) is the treatment of addiction with medications, commonly used for opioid use disorders
  • A long held belief is MAT simply replaces one addiction for another, which is patently false
  • MAT is one of the most affective methods to treat a patient with opioid addiction
  • Unfortunately, outdated requirements for prescribers along further prevent its widespread use

References:

Salsitz E, Wiegand T. Pharmacotherapy of Opioid Addiction: “Putting a Real Face on a False Demon.” Journal of Medical Toxicology. 2016;12(1):58-63. doi:10.1007/s13181-015-0517-5.

Duber HC, Barata IA, Cioè-Peña E, Liang SY, Ketcham E, Macias-Konstantopoulos W, Ryan SA, Stavros M, Whiteside LK. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):420-431. doi: 10.1016/j.annemergmed.2018.04.007. Epub 2018 Jun 5. Review. PubMed PMID: 29880438.


Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

Oct 20, 2018
Podcast #393: Neonatal Vomiting
05:37

 Author: Peter Bakes, MD

Educational Pearls:

 

  • Important historical information to elicit is the birth history, feeding habits, stooling habits, associated symptoms, presence of bile, and presence of trauma.
  • Volvulus is a common etiology of intestinal obstruction and is often due to malrotation in utero.

 

Editor’s note: get an upper GI series if there is any bilious vomiting in a neonate. Any time of the night. Wake people up. Transfer if necessary to get the study. This can diagnose volvulus and save bowel.

References:

Ratnayake K, Kim TY. Evidence-based management of neonatal vomiting in the emergency department. Pediatr Emerg Med Pract. 2014 Nov;11(11):1-20;  Review. PubMed PMID: 25928976.

Burge DM. The management of bilious vomiting in the neonate. Early Hum Dev. 2016 Nov;102:41-45. doi: 10.1016/j.earlhumdev.2016.09.002. Epub 2016 Sep 12. Review. PubMed PMID: 27634337.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD


Oct 17, 2018
Podcast # 392: Maggot Therapy
03:46

Author: Jared Scott, MD

Educational Pearls:

  • Interest started as it was noticed soldiers who had wounds infected with maggots had better outcomes than those without maggots
  • Studies have shown that wound care with maggots is essentially equivalent to traditional therapy with oxygen, antibiotics, and debridement
  • Maggots debride the wound with proteolytic enzymes, sterilize the wound, and stimulate wound healing

References:

Sherman RA. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009 Mar 1;3(2):336-44. Review. PubMed PMID: 20144365; PubMed Central PMCID: PMC2771513.

Baer WS. The treatment of chronic osteomyelitis with the maggot (larva of the blow fly) J Bone & Joint Surg. 1931;13:438–475.  DOI: 10.1007/s11999-010-1416-3

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD



Oct 15, 2018
Podcast # 391: Necrotizing Fasciitis
06:45

Author: Peter Bakes, MD

Educational Pearls:

 

  • Necrotizing fasciitis is an infection of the deep soft tissues with destruction of the muscle fascia and overlying fat
  • Think of it if pain is out of proportion to your exam
  • Polymicrobial and Clostridium species typically cause condition in susceptible individuals (immunocompromised, diabetics, obese, penetrating injury)
  • Group A strep typically is less specific and can cause necrotizing infections in otherwise healthy individuals
  • Treatment is typically rapid surgical debridement in addition to broad spectrum antibiotics in addition to clindamycin

 

References:

Breyre A, Frazee BW. Skin and Soft Tissue Infections in the Emergency Department. Emerg Med Clin North Am. 2018 Nov;36(4):723-750. doi: 10.1016/j.emc.2018.06.005. Review. PubMed PMID: 30297001.

Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7;377(23):2253-2265. doi: 10.1056/NEJMra1600673. Review. PubMed PMID: 29211672.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD





Oct 12, 2018
Podcast # 390: Haloperidol for Pain
05:21

Author: Gretchen Hinson, MD

Educational Pearls:

 

  • Reasonable approach of haloperidol 10 mg IM (or 5 mg IV) for pain relief in opioid-dependent patients; can repeat once
  • Chronic opioid use results in hyperalgesia and a narrow therapeutic window in the long-term so alternatives are essential
  • Consider the risk of QTc prolongation with haloperidol, particularly if the patient is on other drugs that may do so

Editor's note: Interested in more alternatives to opioids? Check out the Colorado ACEP Opioid Prescribing & Treatment Guidelines and the impact these have had in Colorado

References:

http://ercast.libsyn.com/haloperidol-for-analgesia

Ramirez R, Stalcup P, Croft B, Darracq MA. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med. 2017 Aug;35(8):1118-1120. doi: 10.1016/j.ajem.2017.03.015. Epub 2017 Mar 12. PubMed PMID: 28320545.

Seidel S, Aigner M, Ossege M, Pernicka E, Wildner B, Sycha T. Antipsychotics for acute and chronic pain in adults. Cochrane Database Syst Rev. 2013 Aug 29;(8):CD004844. doi: 10.1002/14651858.CD004844.pub3. Review. PubMed PMID: 23990266.




Oct 10, 2018
Podcast #389: BRUE
04:06

Educational Pearls:

 

  • BRUE (Brief Resolved Unexplained Event) replaces what was previously called ALTE
  • BRUE describes an event in a child less than one year of age with one or more of the following:
    • cyanosis or pallor
    • absent, decreased, or irregular breathing
    • decreased or increased tone
    • altered responsiveness
  • These must be sudden, brief, and now resolved and without an alternative explanation after a history and physical exam
  • Low risk patients can be safely discharged with reassurance
  • Low risk criteria must all be present:
    • Age over 60 days old
    • >32 weeks gestational age at birth and adjusted gestational age > 45 weeks)
    • No CPR was performed (by a trained medical professional)
    • First event
    • Duration less than 1 minute of event
  • Patients who satisfy above criteria can be considered low risk and may be discharged after minimal/no workup

 

References:

Tieder JS, Bonkowsky JL, Etzel RA, et al. Clinical Practice Guideline: Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016:137(5):e20160591. Pediatrics. 2016 Aug;138(2). pii: e20161488. doi: 10.1542/peds.2016-1488. PubMed PMID: 27474017.

 

Summary by Travis Barlock, MS4    |   Edited by Erik Verzemnieks, MD

Oct 08, 2018
Podcast #388: Antibiotics for Appendicitis
02:47

Author:  Aaron Lessen, MD

Educational Pearls:

 

  • 5-year follow up study on antibiotic treatment for uncomplicated appendicitis showed 39.1% recurrence rate requiring appendectomy by 5 years
  • Nearly 60% chance then of preventing an appendectomy by using antibiotics only for uncomplicated appendicitis

 

Editor’s note: not surprisingly, complications were much higher in the group receiving surgery, which reiterates why an antibiotic-only approach is attractive for the right patient population

References:

Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Mecklin JP, Sand J, Virtanen J, Jartti A, Grönroos JM. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018 Sep 25;320(12):1259-1265. doi: 10.1001/jama.2018.13201. PubMed PMID: 30264120.

Summary by Travis Barlock, MS4    |   Edited by Erik Verzemnieks, MD

 

Oct 05, 2018
Podcast #387: Fluoroquinolones are Perfectly Safe?
03:26

Author:  Don Stader, MD

Educational Pearls:

 

  • Fluoroquinolones can cause connective tissue disruption leading not only to tendon rupture but also aortic dissection
  • Retrospective study from Taiwan showed over a 2x higher rate of dissection when exposed to fluoroquinolones (1.6% vs 0.6%)
  • Remember to think about aortic dissection when you have a patient with chest pain that travels and/or involves neurologic symptoms
  • Try to use fluoroquinolones when no other appropriate antibiotic exists as they have significant other side effects as well

 

Editor’s note:  In July 2018, the FDA required strengthening of warning labels on fluoroquinolones about the risks of mental health effects and hypoglycemia

References:

Lee CC, Lee MG, Hsieh R, Porta L, Lee WC, Lee SH, Chang SS. Oral Fluoroquinolone and the Risk of Aortic Dissection. J Am Coll Cardiol. 2018 Sep 18;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067. PubMed PMID: 30213330.

Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin Infect Dis. 2003 Jun 1;36(11):1404-10. Epub 2003 May 20. Review. PubMed PMID: 12766835.

https://www.fda.gov/downloads/Drugs/DrugSafety/UCM612834.pdf

 

Summary by Travis Barlock, MS4    |   Edited by Erik Verzemnieks, MD


Oct 03, 2018
Podcast #386: Respecting Transgender Patients
03:21

Author:  Kasey Champion, MD

Educational Pearls:

 

  • Transgender populations are frequent victims of discrimination in healthcare
  • Ask transgender patients what their preferred pronoun is
  • It is sometimes important to ask about transition status (i.e. on hormones, surgery)

 

 

References:

Chisolm-Straker M, Willging C, Daul AD, McNamara S, Sante SC, Shattuck DG 2nd, Crandall CS. Transgender and Gender-Nonconforming Patients in the Emergency Department: What Physicians Know, Think, and Do. Ann Emerg Med. 2018 Feb;71(2):183-188.e1. doi: 10.1016/j.annemergmed.2017.09.042. Epub 2017 Nov 3. PubMed PMID: 29103796.

Oct 01, 2018
Podcast #385: Probiotics
02:56

Author:  John Winkler, MD

Educational Pearls:

  • Probiotics are bacteria that are ingested to promote gut health but recent research casts doubt on their effectiveness.
  • Recent study suggests that most probiotics that are ingested are killed by stomach acid. Those that remain are not very healthy and are outcompeted by the normal gut flora.
  • Probiotics should not be given as a one-size-fits-all treatment.

 

References:

Zmora N, Zilberman-Schapira G, Suez J, Mor U, Dori-Bachash M, Bashiardes S, Kotler E, Zur M, Regev-Lehavi D, Brik RB, Federici S, Cohen Y, Linevsky R, Rothschild D, Moor AE, Ben-Moshe S, Harmelin A, Itzkovitz S, Maharshak N, Shibolet O, Shapiro H, Pevsner-Fischer M, Sharon I, Halpern Z, Segal E, Elinav E. Personalized Gut Mucosal Colonization Resistance to Empiric Probiotics Is Associated with Unique Host and Microbiome Features. Cell. 2018 Sep 6;174(6):1388-1405.e21. doi: 10.1016/j.cell.2018.08.041. PubMed PMID: 30193112.

Sep 28, 2018
Podcast #384: Don’t stab a PTA?
03:24

Author:  Don Stader, MD

Educational Pearls:

 

  • Recent study suggests we may not need to drain uncomplicated peritonsillar abscesses
  • Patients who received medical therapy alone had no difference in complications and failure compared to those who received surgical drainage plus medical therapy
  • Medical therapy in study was ceftriaxone, clindamycin, and dexamethasone
  • Medical therapy was also associated with fewer opioid prescriptions, sore days, and days off from work.

 

References:

Battaglia A, Burchette R, Hussman J, Silver MA, Martin P, Bernstein P. Comparison of Medical Therapy Alone to Medical Therapy with Surgical Treatment of Peritonsillar Abscess. Otolaryngol Head Neck Surg. 2018 Feb;158(2):280-286. doi: 10.1177/0194599817739277. Epub 2017 Nov 7. PubMed PMID: 29110574.

 

Sep 26, 2018
Podcast #383: Prehospital Tubes
04:20

Author:  Sam Killian, MD

Educational Pearls:

 

  • Two high quality randomized control trials published in 2018 demonstrated no difference in mortality or neurologic outcomes when using a supraglottic airway compared to endotracheal intubation in out of hospital cardiac arrest
  • These two trials enrolled over a combined 12000 patients
  • Supraglottic airways have a higher success rate than intubations

 

References:

Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):779-791. doi: 10.1001/jama.2018.11597. PubMed PMID: 30167701

Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):769-778. doi: 10.1001/jama.2018.7044. PubMed PMID: 30167699.



Sep 24, 2018
Podcast #382: Shoulder Separations
03:50

Author:  Ryan Circh, MD

Educational Pearls:

 

  • A “shoulder separation” is when the clavicle separates from the scapula - also referred to as an acromio-clavicular (AC) separation
  • Diagnosis is clinical: pain over AC joint, pain with adduction, and difficulty raising harm past horizontal
  • Early range of motion can be critical for recovery

 

 

References:

Lemos MJ. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med. 1998 Jan-Feb;26(1):137-44. Review. PubMed PMID: 9474415.

Monica J, Vredenburgh Z, Korsh J, Gatt C. Acute Shoulder Injuries in Adults. Am Fam Physician. 2016 Jul 15;94(2):119-27. Review. PubMed PMID: 27419328.


Sep 21, 2018
Podcast #381: MRI... Burns?
03:08

Author:  Sam Killian, MD

Educational Pearls:

  • MRI machines can generate enough heat from the radiofrequency to cause thermal burns

 

  • Patients with EKG stickers, medication patches, clothing impregnated with metallic ions, etc., can all increase risk of burns
  • Even skin-to-skin contact within the patient can cause a misinterpretation from the software and increased energy, leading to burn

 

References:

Cross NM, Hoff MN, Kanal KM. Avoiding MRI-Related Accidents: A Practical Approach to Implementing MR Safety. J Am Coll Radiol. 2018 Aug 24. pii: S1546-1440(18)30762-2. doi: 10.1016/j.jacr.2018.06.022. [Epub ahead of print] PubMed PMID: 30149951.

Takahashi T, Fujimoto N, Hamada Y, Tezuka N, Tanaka T. MRI-related thermal injury due to skin-to-skin contact. Eur J Dermatol. 2016 Jun 1;26(3):296-8. doi: 10.1684/ejd.2016.2740. PubMed PMID: 26987101.

Pietryga JA, Fonder MA, Rogg JM, North DL, Bercovitch LG. Invisible metallic microfiber in clothing presents unrecognized MRI risk for cutaneous burn. AJNR Am J Neuroradiol. 2013 May;34(5):E47-50. doi: 10.3174/ajnr.A2827. Epub 2011 Dec 15. PubMed PMID: 22173750.

Dempsey MF, Condon B. Thermal injuries associated with MRI. Clin Radiol. 2001 Jun;56(6):457-65. Review. PubMed PMID: 11428795.




Sep 19, 2018
Podcast #380: Oxygen for the kill
03:10

Author:  Ryan Circh, MD

Educational Pearls:

 

  • Review of 25 randomized control trials encompassing 16,037 acutely ill hospitalized patients
  • Patients given oxygen with saturations > 94% on room air were found to have associated increased mortality in-hospital, at 30-days, and at long-term follow up
  • It may seem intuitive, but do not give oxygen to patients that do not need it

 

References:

Chu DK, et al (2018). Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 391(10131):1693-1705

Sep 17, 2018
Podcast #379: Patient Perspectives of the Flu
04:54

Author:  Sam Killian, MD

Educational Pearls:

 

  • Patients may have certain fears or expectations about the flu based on hearsay and other less reliable sources
  • Taking extra time explaining the risks of the flu may help base these expectations more in reality
  • This includes providing good return precautions and acknowledging that the disease can still be unpredictable

 

 

Sep 14, 2018
Podcast #378: Is That a Brown Recluse Spider Bite?
04:17

Author:  Michael Hunt, MD

Educational Pearls:

 

  • Use the mnemonic NOT RECLUSE to rule out a brown recluse spider bite:
  • Numerous bites (recluse spiders will bite once)
  • Occurence (recluse bites between April- October)
  • Timing (recluse spiders are… get this…  reclusive)
  • Red (recluse bites are white/pale)
  • Elevated (recluse bites are flat)
  • Chronic (recluse bites are acute)
  • Large (recluse wounds are small)
  • Ulceration, early (recluse bites ulcerate between 7-14 days)
  • Swollen (recluse bites are flat)
  • Exudative (recluse bites are dry)

 

References:

Stoecker WV, Vetter RS, Dyer JA. NOT RECLUSE-A Mnemonic Device to Avoid False Diagnoses of Brown Recluse Spider Bites. JAMA Dermatol. 2017 May 1;153(5):377-378. doi: 10.1001/jamadermatol.2016.5665. PubMed PMID: 28199453.

Sep 12, 2018
Podcast #377: Endocarditis
03:37

Author:  Nick Tsipis, MD

Educational Pearls:

 

  • Persistent fever or positive blood cultures should raise suspicion for endocarditis
  • Patients with recent dental procedures, recent cardiac surgeries are at risk, or who inject drugs are at higher risk
  • Physical exam findings may include fever with a new murmur, Janeway lesions, Osler nodes, and/or splinter hemorrhages

 

References:

Long B, Koyfman A. Infectious endocarditis: An update for emergency clinicians. Am J Emerg Med. 2018 Sep;36(9):1686-1692. doi: 10.1016/j.ajem.2018.06.074. Epub 2018 Jul 2. Review. PubMed PMID: 30001813.

Murdoch DR, Corey GR, Hoen B et. al. International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009 Mar 9;169(5):463-73. doi: 10.1001/archinternmed.2008.603

Sep 10, 2018
Podcast #376: Alcohol Intoxication
04:39

Educational Pearls:

 

  • Blood concentrations over 0.4 mg/dL  is associated with respiratory depression and possible death in alcohol naive patients
  • Alcohol overdose accounts to 2,200 deaths per year
  • Don’t forget about checking for hypoglycemia in severe alcohol intoxication
  • Consider ketamine for agitation to prevent further respiratory depression

 

Editor’s note: check out our podcast on ketamine for alcohol withdrawal here

References:

Jung YC, Namkoong K. Alcohol: intoxication and poisoning - diagnosis and treatment. Handb Clin Neurol. 2014;125:115-21. doi: 10.1016/B978-0-444-62619-6.00007-0.

Centers for Disease Control and Prevention (CDC). "Vital signs: binge drinking prevalence, frequency, and intensity among adults-United States, 2010." MMWR. Morbidity and mortality weekly report 61.1 (2012): 14.


Sep 08, 2018
Podcast #375: Retrograde Urethrogram
05:04

Author:  Jared Scott, MD

Educational Pearls:

 

  • Blood at urethral meatus in trauma can be a sign of bladder/urethral injury
  • Blind placement of a Foley catheter can make an undiagnosed urethral injury worse
  • Urethral injury is evaluated using a retrograde urethrogram (RUG)
  • If urethra is confirmed to be intact, Foley catheter can be placed to allow additional tests

 

References:

Avery, L. (2012). Imaging of male pelvic trauma. Radiologic Clinics of North America., 50(6), 1201-1217.



Sep 06, 2018
Podcast #374:  Iliac Artery Endofibrosis
03:18

Author:  Sue Chilton, MD

Educational Pearls:

 

  • An unusual cause of leg pain that can mimic sciatica/claudication
  • Predominantly occurring in high endurance athletes, particularly cyclists and runners
  • More common in men
  • Check supine ABIs 1 minute after activity in the ED: a value < 0.5 is 80% sensitive

 

References:

Mansour A, Murney S, Jordan K, Laperna L. Endofibrosis: an unusual cause of leg pain in an athlete. J Sports Med Phys Fitness. 2016 Jan-Feb;56(1-2):157-61. Epub 2015 Jul 3. PubMed PMID: 26140352.

Peach G, Schep G, Palfreeman R, Beard JD, Thompson MM, Hinchliffe RJ. Endofibrosis and kinking of the iliac arteries in athletes: a systematic review. Eur J Vasc Endovasc Surg. 2012;43(2):208–17.

 

Sep 04, 2018
Podcast # 373: Legionnaires Disease
03:59

Author:  Gretchen Hinson, MD

Educational Pearls:

 

  • Legionnaires disease refers to a severe pneumonia caused by Legionella pneumophilia and occurs typically at the extremes of age
  • Associated gastrointestinal symptoms (nausea/vomiting/diarrhea) may be present
  • Hyponatremia is a common laboratory finding
  • Legionella urinary antigen can be a convenient test to identify the infection
  • Treatment is with fluoroquinolones, macrolides and/or tetracyclines

 

 

References

Pierre DM, Baron J, Yu VL, Stout JE. Diagnostic testing for Legionnaires’ disease. Annals of Clinical Microbiology and Antimicrobials. 2017;16:59. doi:10.1186/s12941-017-0229-6.

Cunha BA, Cunha CB. Legionnaire's Disease and its Mimics: A Clinical Perspective. Infect Dis Clin North Am. 2017 Mar;31(1):95-109. doi: 10.1016/j.idc.2016.10.008. Review.



Sep 01, 2018
Podcast # 372: The Latest on Epinephrine in Cardiac Arrest
03:39

Author:  Don Stader, MD

Educational Pearls:

 

  • 8014 patients with out-of-hospital cardiac arrest randomized to epinephrine vs placebo
  • 30-day survival was not dramatically better between groups (3.2%in the epinephrine group and 2.4% in the placebo group)
  • Functional neurological outcome was nearly identical at 2.2% and 1.9% of patients
  • Adds to literature that epinephrine provides little important benefit in cardiac arrest - focus on chest compressions and early defibrillation

 

Editor’s note: NNT for epinephrine to prevent one death in this study was 115 - compared to bystander CPR (NNT 15) and defibrillation (NNT 5) from prior studies.

 

References

Perkins GD et. al. . A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest.    N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18.

Kitamura T, Kiyohara K, Sakai T, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med 2016;375:1649-1659.

Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307-2315.

Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294. PubMed PMID: 22436956.

Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med. 2015 Feb;175(2):196-204. doi: 10.1001/jamainternmed.2014.5420.

Aug 30, 2018
Podcast # 371: EKG changes of Hyperkalemia
03:19

Author:  Jared Scott, MD

Educational Pearls:

 

  • EKG changes do not necessarily correlate to degree of hyperkalemia
  • Traditional progression through peaked T-waves, flattened p-waves, QRS widening, and then sine-waves before asystole

 

 

References

Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721–729.



Aug 28, 2018
Podcast # 370:  Rapid Fire Neonatal Resuscitation
01:57

Author:  Erik Verzemnieks, MD

Educational Pearls:

 

  • In the panic of a precipitous ED delivery, remember: Warm. Dry. Stim.  It will solve most of your problems in most scenarios
  • Start compressions if heart rate is less than 60
  • Put the pulse ox on the right hand - it may make a difference as it is preductal

 

Editor’s note: detecting a heart rate can be tough in a newborn - you can feel the umbilical stump or just listen with your stethoscope

 

References

Gary Weiner & Jeanette Zaichkin. Textbook of Neonatal Resuscitation (NRP), 7th Ed, 2016. American Academy of Pediatrics & American Heart Association.



Aug 24, 2018
Podcast # 369:  Five powerful toxins - the definitive list?
03:47

Author: Michael Hunt, MD

Educational Pearls:

Here is a list of some very toxic natural substances:

 

 

#5: Tetrodotoxin: Found in pufferfish and other aquatic species

#4: Ricin: made from castor beans

#3: Mercury: natural element absorbable through skin and gloves

#2: Batrachotoxin: found on poison dart frogs

#1: Botulinum toxin: produced by Clostridium botulinum and causes a descending paralysis

Editor's note: batrachotoxin is thought to be accumulated by the beatles and other insects dart frogs eat - those in captivity therefore are not poisonous

References

https://theconversation.com/handle-with-care-the-worlds-five-deadliest-poisons-56089



Aug 22, 2018
Podcast # 368: Prehospital Plasma
02:07

Author: Aaron Lessen, MD

Educational Pearls:

 

  • Non-blinded randomized study assessing 30-day mortality benefit from plasma-first resuscitation in patients at risk hemorrhagic shock
  • Study involved aeromedical transport of trauma patients
  • 30-day mortality 23.2 % in intervention group vs. 33.0% in standard care group

 

Editor's note: a similar study published in Lancet at the same time showed no mortality benefit from prehospital administration of plasma in a slightly different population which had much shorter ground transport times a major trauma center

References

Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, Adams PW, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Duane TM, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Rosengart MR, Forsythe RM, Billiar TR, Yealy DM, Peitzman AB, Zenati MS; PAMPer Study Group.. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326. doi: 10.1056/NEJMoa1802345.

Aug 20, 2018
Podcast # 367: Digital Necrosis after Epinephrine Drip
04:55

Podcast # 367: Digital Necrosis after Epinephrine Drip

Author: Jared Scott, MD.

Educational Pearls:

 

  • Make sure to monitor for limb ischemia in all patients on vasopressors
  • Good reminder that vasopressors are not risk free - use them only on patients that need them!

 

References

Daroca-Pérez, R., & Carrascosa, M. F. . Digital necrosis: a potential risk of high-dose norepinephrine. Therapeutic Advances in Drug Safety. 2017. 8(8), 259–261. http://doi.org/10.1177/2042098617712669.



Aug 17, 2018
Podcast # 366: Ehlers Danlos
04:05

Podcast # 366: Ehlers Danlos

Author: Gretchen Hinson, MD.

Educational Pearls:

 

  • Heritable mutation in collagen synthesis and expression commonly resulting in joint hyperextension and skin elasticity.
  • Vascular type can result in aneurysm formation and rupture in young patients.
  • Patients are also at risk for spontaneous bowel rupture.
  • Pregnant women can present with uterine rupture.

 

References

Byers PH, Murray ML (2012). "Heritable collagen disorders: the paradigm of Ehlers–Danlos syndrome". Journal of Investigative Dermatology. 132 (E1): E6–11.

Pepin MG, Byers PH. Ehlers-Danlos Syndrome Type IV. In: Pagon RA, Bird TD, Dolan CR, et al., eds. GeneReviews [Internet]. Seattle (WA): University of Washington, Seattle; 1993-.

Yoneda, A., Okada, K., Okubo, H., Matsuo, M., Kishikawa, H., Naing, B. T., … Shimada, T. (2014). Spontaneous Colon Perforations Associated with a Vascular Type of Ehlers-Danlos Syndrome. Case Reports in Gastroenterology, 8(2), 175–181. http://doi.org/10.1159/000363373

Aug 15, 2018
Podcast # 365: Renal Trigger Point Injections
01:45

Author: Erik Verzemnieks, MD

Educational Pearls:

 

  • Single study in Japan demonstrated possible effectiveness of renal colic trigger point
  • Patients had injection at the area of maximal tenderness on palpation of the flank
  • Compared to a muscle relaxer, injection of local anesthetic at the trigger point had faster time to pain relief and fewer rescue therapies 

References

Iguchi, M et al. Randomized trial of trigger point injection for renal colic. International Journal of Urology. 2002. 9(9): 475-479



Aug 13, 2018
Podcast # 364: Other causes of ST elevation
06:07

Author: Peter Bakes, MD

Educational Pearls:

 

  • Pericarditis, LBBB, LVH and left ventricular aneurysms can all present with ST elevation.
  • Ventricular aneurysm will present days after a cardiac event with ST elevation and Q waves in the affected leads.
  • Ventricular aneurysms may cause papillary muscle dysfunction with a resultant holosystolic murmur and even heart failure.

 

References

Victor F. Froelicher; Jonathan Myers (2006). Exercise and the heart. Elsevier Health Sciences. pp. 138–. ISBN 978-1-4160-0311-3.

Nagle RE, Williams DO. (1974) Proceedings: Natural history of ventricular aneurysm without surgical treatment. British Heart Journal, 36:1037.

Aug 10, 2018
Podcast # 363: Ketamine for Alcohol Withdrawal
02:10

Educational Pearls:

 

  • Recent study has shown adjunctive ketamine can be useful in setting of alcohol withdrawal.
  • Ketamine was associated with a decrease in the amount of benzodiazepines needed, likelihood of intubation, and a decrease in ICU length of stay by 3 days.
  • For patients with benzodiazepine resistance, ketamine was shown to have symptom relief in an hour and decreased rate of benzodiazepine infusion.

 

References

Pizon A, Lynch M, Benedict N, et al. 2018. Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal. Critical Care Medicine. 46(8):e768-e771.

Shah, P., McDowell, M., Ebisu, R. et al. J. Med. Toxicol. (2018). https://doi.org/10.1007/s13181-018-0662-8

Aug 08, 2018
Podcast # 362: Giant Hogweed
02:22

Author: John Winkler, MD

Educational Pearls:

 

  • Tall flowering plant with phototoxic sap
  • Direct skin contact with the sap can cause the skin to become photosensitive
  • Severe blisters and even burns can result

 

References

Diebel, Matthew (18 June 2018). "Giant Hogweed, a Plant That Can Cause Burns and Blindness, Found in Virginia". USA Today.



 

Aug 06, 2018
Podcast # 361: Vertiginous Dizziness
06:09

Author: Peter Bakes, MD

Educational Pearls:

 

  • Important to find out if patients mean dysequilibrium, lightheadedness, or vertigo when patients say they are “dizzy.”
  • Differentiate central vs. peripheral vertigo
  • Central vertigo typically present with bulbar syndromes (difficulty swallowing, facial nerve palsy) and cerebellar symptoms (ataxia).
  • Peripheral vertigo typically present with sudden onset vertigo with nausea and vomiting in the absence of bulbar symptoms.
  • Episodic? BPPV or Meniere’s Disease. BPPV has not auditory symptoms and is associated with head position; Meniere’s has hearing loss, tinnitus, and ear fullness.
  • Constant? Neuronitis has no auditory symptoms, while labyrinthitis has associated hearing loss/tinnitus and is associated with a recent infection (OM).

 

References

Baloh RW. Differentiating between peripheral and central causes of vertigo. Otolaryngol Head Neck Surg 1998; 119:55.

Chase M, Goldstein JN, Selim MH, et al. A prospective pilot study of predictors of acute stroke in emergency department patients with dizziness. Mayo Clin Proc 2014; 89:173.

Kerber KA, Brown DL, Lisabeth LD, et al. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 2006; 37:2484.


Aug 03, 2018
Podcast # 360: Epidural Abscess Screening
04:47

Author: Dylan Luyten, MD.

Educational Pearls:

 

  • Dangerous causes of back pain: AAA, cauda equina syndrome, epidural abscess.
  • Young person with back pain needs to be evaluated for injection drug use (major risk factor).
  • Patient with focal neurologic deficits (FND) require an MRI.  Patients without FND can be screened with ESR and CRP. An ESR < 20 & CRP < 1 can effectively rule out epidural abscess as it has a 90% sensitivity for epidural abscess.
  • Treatment is IV antibiotics and surgical debridement.

 

References

Davis DP et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain, Journal of Neurosurgery: Spine. 2011. 14:765-770.

Aug 02, 2018
Podcast # 359: Normal EKG
04:27

Author: Sam Killian, MD.

Educational Pearls:

 

  • Computer interpretation has a very good negative predictive value of a normal EKG (99%).
  • Of 222 interpreted as “normal,” 13 were deemed to have some abnormality by a cardiologist in a recent study.
  • Those 13 EKG’s were read by 2 ER docs, and only 1 missed interpretation warranted a move from triage to a bed.

 

References

Katie E. Hughes KE., Scott M. Lewis SM., Laurence Katz and Jonathan Jones  Safety of Computer Interpretation of Normal Triage Electrocardiograms. 2017. Academic Emergency Medicine 24(1):120-124. http://onlinelibrary.wiley.com/doi/10.1111/acem.13067/full.

Jul 31, 2018
Podcast # 358: Affordable ear drop alternatives
01:41

Author: Erik Verzemnieks, MD

Educational Pearls:

 

  • Otic (ear) specific antibiotic drops can be expensive
  • Opthalmic (eye) versions are basically identical and can be used as an affordable substitute as many are on the $4 drug lists
  • But don’t do the reverse (don't use ear drops on the eye)
  • Use caution when administering aminoglycoside if tympanic membrane rupture is present

 

References

https://tgtfiles.target.com/pharmacy/WCMP02-032536_RxGenericsList_NM7.pdf

http://i.walmart.com/i/if/hmp/fusion/four_dollar_drug_list.pdf

https://www.uptodate.com/contents/external-otitis-treatment

 


Jul 27, 2018
Podcast #357: Local Anesthetic Toxicity
04:28

Author: Michael Hunt, MD

Educational Pearls:

 

  • Toxicity happens from local anesthetics being given too fast, too much, or in the unintended spot
  • Systemic toxicity manifests first with neurologic symptoms like circumoral numbness, tinnitus, blurred vision, nausea, and even seizures. Severe toxicity can then progress to arrhythmias and cardiac arrest.
  • Maximum doses of lidocaine: 4 mg/kg; and with epinephrine: 7mg/kg.
  • Maximum dose of bupivacaine: 2mg/kg; with epinephrine 3mg/kg

 

Editor note: treat seizures with benzodiazepines and avoid propofol for sedation; severe toxicity can also be treated with a 20%  lipid emulsion, though there is debate on its efficacy

 

References

Dickerson DM, Apfelbaum JL. Local anesthetic systemic toxicity. Aesthet Surg J. 2014 Sep;34(7):1111-9. doi: 10.1177/1090820X14543102.

Neal JM, Mulroy MF, Weinberg GL; American Society of Regional Anesthesia and Pain Medicine.. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8. doi: 10.1097/AAP.0b013e31822e0d8a.

Vasques F, Behr AU, Weinberg G, Ori C, Di Gregorio G. A Review of Local Anesthetic Systemic Toxicity Cases Since Publication of the American Society of Regional Anesthesia Recommendations: To Whom It May Concern. Reg Anesth Pain Med. 2015 Nov-Dec;40(6):698-705. doi: 10.1097/AAP.0000000000000320.

 

Jul 25, 2018
Podcast # 356: Babies can’t be born addicted
04:56

Author: Don Stader, MD.

Educational Pearls:

 

  • A baby can be born dependent on opioids but not addicted to them.
  • Opioid addiction (Opioid Use Disorder) is a disease of mature brains and is characterized by compulsive drug use despite adverse consequences.
  • Opioid addiction is a disease that affects the reward center of the brain
  • Pregnant patients struggling with addiction do better when started on buprenorphine or methadone. This treatment will cause opioid withdrawal syndrome in newborns, but not the long term morbidity and mortality of illicit opioids.

 

References

Gowing L, Farrell MF, Bornemann R, Sullivan LE, Ali R. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database of Systematic Reviews 2011, Issue 8: CD004145. DOI: 10.1002/14651858.CD004145.pub4.

Volkow ND, Koob GF, McLellan AT ( 2016). "Neurobiologic Advances from the Brain Disease Model of Addiction." New England Journal of Medicine. 374 (4): 363–371.

Jul 23, 2018
Podcast #355: Syphilis
03:36

Author: Aaron Lessen, MD

Educational Pearls:

 

  • Re-emerging STI.
  • Progresses through distinct phases if untreated:
  • Primary syphilis: frequently overlooked because initial chancre is painless.
  • Secondary syphilis: viral syndrome, rash on trunk, palms, and soles.
  • Latent syphilis: asymptomatic period, lasting 5-20 years.
  • Tertiary syphilis: includes neurosyphilis (dementia, encephalitis, etc.) and cardiovascular syphilis (aortitis, etc).
  • Treatment penicillin G 2.4 million units once for primary or secondary treatment; once weekly for 3 weeks for latent/tertiary.

 

References

Mattei, P., Beachkofsky, T., Gilson, R., Wisco, O. Syphilis: A reemerging infection. 2012. American Family Physician., 86(5), 433-440.

 

 



Jul 20, 2018
Podcast # 354: Hematometra
04:09

Author: Sam Killian, MD

Educational Pearls:

 

  • Hematometra: uterus filled with blood due to obstruction of outflow tract.
  • Most commonly a result congenital abnormalities (imperforate hymen, transverse vaginal septum, etc.) but can be acquired due to cervical stenosis, intrauterine adhesions, neoplasms, and post-surgical scarring.
  • Symptoms include: pain, abnormal bleeding, enlarged uterus
  • Diagnosis: commonly achieved by ultrasound and physical exam.
  • Treatment is surgical (cervical dilatation, hysteroscopy, etc.).

 

References

U Nayak A, Swarup A, G S J, N S. Hematometra and acute abdomen. Journal of Emergencies, Trauma and Shock. 2010;3(2):191-192. doi:10.4103/0974-2700.62117.

Kotter HC, Weingrow D, Canders CP. Hematometrocolpos in a Pubescent Girl with Abdominal Pain. Clinical Practice and Cases in Emergency Medicine. 2017;1(3):218-220. doi:10.5811/cpcem.2017.3.33369.

Jul 18, 2018
Podcast # 353: Xofluza
03:25

Author: Sam Killian, MD

Educational Pearls:

 

  • Japan recently approved baloxavir marboxil (Xofluza), which may potentially "kill" Flu A/B within 24 hours
  • Recent RCT trial showed superiority over oseltamavir (Tamiflu) in cessation of viral shedding (24 vs 72 hours)
  • Compared to placebo, superior in time to symptom resolution (53.7 vs 80.7  hours)
  • Administered as single dose
  • Yet to be considered for FDA approval

 

References

Portsmouth S, Kawaguchi K, Arai M, Tsuchiya K, Uehara T. Cap-dependent Endonuclease Inhibitor S-033188 for the Treatment of Influenza: Results from a Phase 3, Randomized, Double-Blind, Placebo- and Active-Controlled Study in Otherwise Healthy Adolescents and Adults with Seasonal Influenza. Open Forum Infectious Diseases. 2017;4(Suppl 1):S734. doi:10.1093/ofid/ofx180.001.



 

Jul 16, 2018
Podcast #352: TXA for Epistaxis
03:43

Podcast #352: TXA for Epistaxis

Author:  Chris Holmes, M.D.

Educational Pearls:

 

  • TXA: tranexamic acid; used in control of bleeding in major trauma, postpartum hemorrhage, etc.
  • In study of 216 patients with epistaxis, TXA placed on a pledget was compared to anterior cotton nasal packing.
  • The TXA group had faster time to bleeding control, quicker time to discharge, better patient satisfaction, and lower rates of re-bleeding.

 

References:

Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013 Sep;31(9):1389-92. doi: 10.1016/j.ajem.2013.06.043.

Jul 13, 2018
Podcast #351: Indications for AICD
04:18

Author:  Pete Bakes, MD

Educational Pearls:

 

  • AICD: Automated Implantable Cardioverter-Defibrillator.
  • Can be placed for secondary prevention of cardiac arrest (i.e. history of cardiac arrest not from reversible cause).
  • Also indications for primary prevention: EF 35% or less; ventricular tachycardia with underlying structural heart disease; Brugada; genetic-induced prolonged QT-syndromes.

 

References:

Al-Khatib SM et. al. 2017 AHA/ACC/HRS Guideline 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 on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017 Oct 30. pii: S1547-5271(17)31249-3. doi: 10.1016/j.hrthm.2017.10.035.

Jul 11, 2018
Podcast # 350: Pressors and Ischemia
03:30

Author: Nick Hatch, MD.

Educational Pearls:

 

  • A common concern using vasopressors is the risk of digital and mesenteric ischemia.
  • The absolute risk of digital ischemia and/or mesenteric ischemia is pretty low. Norepinephrine at its highest doses carries a 5% digital ischemia rate and a 2% mesenteric ischemia rate.
  • The studies demonstrating this complication were predominately patients with pre-existing liver disease.
  • Providers commonly mistake purpura fulminans, a common complication of sepsis, for digital ischemia.

 

References

Brown, SM. et al.  Survival After Shock Requiring High-Dose Vasopressor Therapy. Chest. 2013. 143(3), 664–671. http://doi.org/10.1378/chest.12-1106.

Malay MB et al. Heterogeneity of the vasoconstrictor effect of vasopressin in septic shock. Critical Care Medicine. 2004. 32(6), 1327-31.

Jul 09, 2018
Podcast # 349: Fat Emboli
03:02

Author: Sue Chilton, MD

Educational Pearls:

 

  • Triad of fat emboli syndrome is a petechial rash, AMS, and respiratory distress.
  • Petechiae usually start in the axilla.
  • 90% of patients with long bone fractures will shed fat.
  • May see ground-glass opacities on imaging, but perfusion defects will not be seen on CTA or V/Q scan
  • Patients with a PFO can have cerebral involvement.

 

References

Newbigin K, Souza CA, Torres C, Marchiori E, Gupta A, Inacio J, Armstrong M, Peña E. Fat embolism syndrome: State-of-the-art review focused on pulmonary imaging findings. Respir Med. 2016.113:93-100. doi: 10.1016/j.rmed.2016.01.018.

Kosova E, Bergmark B, Piazza G. Fat embolism syndrome. Circulation. 2015. 20;131(3):317-20. doi: 10.1161/CIRCULATIONAHA.114.010835.



Jul 04, 2018
Podcast # 348: Steakhouse Syndrome
03:36

Author: Don Stader, MD

Educational Pearls:

 

  • Steakhouse syndrome is an impacted esophageal food bolus.
  • Occurs because they have an esophageal stricture (schatzki ring, scarring, esophagitis).
  • Classic treatments have consisted of effervescents, glucagon, and/or sublingual nitroglycerin (NTG).
  • Recent case series has shown oral 400mcg tablet of NTG dissolved in 10cc tap water was 100% successful.
  • Complications of NTG are hypotension and headache.

 

References

Kirchner GI, Zuber-Jerger I, Endlicher E, et al. (2011) Causes of bolus impaction in the esophagus. Surgical Endoscopy. 25:3170.

Willenbring BA, et al. (2018). Oral Nitroglycerin Solution May Be Effective for Esophageal Food Impaction. Journal of Emergency Medicine. 54(5):678-680.

Jul 02, 2018
Podcast # 347: Fasting and Procedural Sedation
03:19

 

Author: Sam Killian, MD

Educational Pearls:

 

  • Recent study examining fasting and adverse events during procedural sedation found no association between fasting duration and any type of adverse event.
  • Of the 6,183 children in the study, about 6 vomited during the procedure, and about 300 vomited recently after the procedure, and there were no episodes of aspiration.

 

References

Bhatt, M, et al.  (2018). Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children. JAMA Pediatrics, doi: 10.1001/jamapediatrics.2018.0830. [Epub ahead of print]


Jun 29, 2018
Podcast # 346: Pediatric DKA
04:17

Author: Chris Holmes, MD

Educational Pearls:

 

  • There is a risk of cerebral edema in pediatrics with DKA if over resuscitated.
  • Recent study comparing normal saline vs. ½ normal saline showed no difference in rates of cerebral edema regardless of rate of infusion.
  • Recommend sticking with a fluid resuscitation protocol you are familiar with (i.e., 2 rounds of 10cc/kg bolus of NS).

 

References

Glaser, N. S., Ghetti, S., Casper, T. C., Dean, J. M., & Kuppermann, N. (2013). Pediatric Diabetic Ketoacidosis, Fluid Therapy and Cerebral Injury: The Design of a Factorial Randomized Controlled Trial. Pediatric Diabetes, 14(6), 435–446. http://doi.org/10.1111/pedi.12027

 

Jun 27, 2018
Podcast # 345: Epidural Abscess
04:37

Author: Sue Chilton, MD

Educational Pearls:

 

  • IV drug use and spinal procedures are major risk factors.
  • Classic triad of back pain, focal neurological deficit and fever. However, presence of fever is highly variable. Neurologic deficits may not present until later, but then they can have a rapid progression of neurological decline.
  • MRSA is most common organism, but GNR and MSSA are also possible.

 

References

Chen WC, Wang JL, Wang JT, et al. (2008). Spinal epidural abscess due to Staphylococcus aureus: clinical manifestations and outcomes. Journal of Microbiology, Immunology and Infection. 41:215.

Danner RL, Hartman BJ. (1987).Update on spinal epidural abscess: 35 cases and review of the literature. Review of Infectious Disease. 9:265.

Pfister H-W, Klein M, Tunkel AR, Scheld WM. Epidural abscess. In: Infections of the Central Nervous System, Fourth Edition, Scheld WM, Whitley RJ, Marra CM (Eds), Wolters Kluwer Health, Philadelphia 2014. p.550.

Jun 25, 2018
Podcast # 344: Foley troubleshooting
03:22

Author: Aaron Lessen, MD.

Educational Pearls:

 

  • When foley is stuck, balloon may not have deflated.
  • Make sure balloon is not in the urethra, which can block drainage.
  • Cut off the port as it may be obstructed.
  • If still not draining, pass guide wire through port to unclog catheter.
  • Other techniques have been described using mineral oil to dissolve, rupturing the balloon through over-inflation, and transcutaneous guided drainage.
  • Crystallization can be a cause of catheter obstruction - sterile water may be a better solution to inflate the ballon than saline when it is first placed.

 

References

Khan SA, Landes F, Paola AS, Ferrarotto L. Emergency management of the nondeflating Foley catheter balloon. Am J Emerg Med. 1991 May;9(3):260-3. PubMed PMID: 2018599.

Hollingsworth M, Quiroz F, Guralnick ML. The management of retained Foley catheters. Can J Urol. 2004 Feb;11(1):2163-6. PubMed PMID: 15003159.

Jun 22, 2018
Podcast # 343: Snake Bites
06:01

Educational Pearls:

 

  • Snake bites commonly occur between April and October.
  • Rattlesnake bites are the most common.
  • Venom contains proteins/enzymes that cause local inflammation, coagulopathy, and systemic effects (hypotension, angioedema, renal failure, etc.) along with neurotoxins may cause fasciculations, ptosis, drooling, or hyporeflexia.
  • Management:
  • Mark site for swelling.
  • Monitor progression.
  • Elevate and immobilize injured limb and treat pain.
  • Check basic labs including coagulation studies, and update tetanus.
  • Antidote is CroFab and use if patient has systemic symptoms.  Anaphylaxis is a known complication of CroFab
  • Avoid: ice, tourniquets, and incision and drainage.

 

References

Hifumi T et. al.. Venomous snake bites: clinical diagnosis and treatment. J Intensive Care. 2015 Apr 1;3(1):16. doi: 10.1186/s40560-015-0081-8.

Warrell DA. Snake bite. Lancet. 2010. 375(9708):77-88. doi: 10.1016/S0140-6736(09)61754-2.

Warrell DA. Envenoming and injuries by venomous and nonvenomous reptiles worldwide. In: Wilderness Medicine, 6th Edition, Auerbach PS (Ed), Elsevier Mosby, Philadelphia 2012. p.1040.

Jun 20, 2018
Podcast # 342: Scombroid
04:54

Author: Jared Scott, MD

Educational Pearls:

  • Scombroid is a type of food poisoning associated with dark fish (i.e. tuna, salmon, mackerel) that mimics anaphylaxis.
  • Occurs through conversion of histidine to histamine by bacteria in the fish.
  • Symptoms include flushing, lips swelling, nausea, diarrhea in setting of recent fish consumption.
  • Treat with antihistamines.

 

References

Ridolo E, Martignago I, Senna G, Ricci G. Scombroid syndrome: it seems to be fish allergy but... it isn't. Curr Opin Allergy Clin Immunol. 2016. 16(5):516-21. doi: 10.1097/ACI.0000000000000297.

Patterson R, Little B, Tolan J, Sweeney C. How to manage a urinary catheter balloon that will not deflate. Int Urol Nephrol. 2006;38(1):57-61. Review. PubMed PMID: 16502053.

Jun 18, 2018
Podcast # 341: Tenecteplase vs. Alteplase
03:09

Author:   Rachel Beham, PharmD

Educational Pearls:

  • Tenecteplase is more specific for fibrin and has a longer half-life than alteplase.
  • In setting of ischemic stroke, tenecteplase before thrombectomy was associated with a statistically higher incidence of reperfusion and better functional outcome than alteplase.

References

Bruce C.V. Campbell B et al (2018). Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. New England Journal of Medicine. 378:1573-1582

Jun 13, 2018
Podcast # 340: Drowning
05:03

Author: Chris Holmes, MD

Educational Pearls:

 

  • Epidemiology: 80% male, ages 1-4 at greatest risk, African-American > Caucasian.
  • Freshwater and ocean water may have more bacteria than pool water.
  • Salt water is hyperosmolar, which theoretically increases risk of pulmonary edema.
  • Greatest physiologic insult is from hypoxia secondary to fluid aspiration or laryngeal spasm. Patient survival is related to presentation on arrival.
  • Workup includes CXR and ABG; consider C-spine immobilization/imaging when cervical injury is strongly suspected (i.e. diving injury).
  • Treatment consists of supplemental oxygen therapy. Consider CPAP or intubation.

 

References

Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012. 366(22):2102-10. doi: 10.1056/NEJMra1013317.

Schmidt A, Sempsrott J. Drowning In The Adult Population: Emergency Department Resuscitation And Treatment. Emerg Med Pract. 2015. 17(5):1-18.

Jun 11, 2018
Podcast # 339: Ectopic Pregnancy Risk Factors
05:25

Author: Jared Scott, MD

Educational Pearls:

  • Data is mixed, but some studies show 1-2% of pregnancies are ectopic.
  • Risk factors for ectopic pregnancies include: pelvic inflammatory disease, prior ectopic pregnancy, prior abdominal surgery, prior abortion, advanced maternal age, IUD, tubal blockage, and smoking (including spouse).
  • Greatest risk factor is a prior ectopic pregnancy, which carries a 17x higher risk.
  • Patients with histories of PID and cigarette smoking present educational opportunities.

 

References

Moini, A., Hosseini, R., Jahangiri, N., Shiva, M., & Akhoond, M. R. (2014). Risk factors for ectopic pregnancy: A case–control study. Journal of Research in Medical Sciences : The Official Journal of Isfahan University of Medical Sciences, 19(9), 844–849.

Rana, P; Kazmi, I; Singh, R; Afzal, M; Al-Abbasi, FA; Aseeri, A; Singh, R; Khan, R; Anwar, F (2013). "Ectopic pregnancy: a review". Archives of Gynecology and Obstetrics. 288 (4): 747–57. doi: 10.1007/s00404-013-2929-2.

Jun 08, 2018
Podcast # 338: Mononucleosis predictors
02:42

Author: Chris Holmes, MD

Educational Pearls:

  • Symptoms commonly seen with mononucleosis are palatal petechiae, posterior cervical lymphadenopathy, inguinal/axillary lymphadenopathy, splenomegaly, and/or atypical lymphocytes > 10% on CBC.
  • Among these, posterior cervical lymphadenopathy and atypical lymphocytes > 10% were the most sensitive (sensitivities of 0.64 and 0.66 respectively).

References

Welch, JL et al. What Elements Suggest Infectious Mononucleosis? Annals of Emergency Medicine. 2018. 71(4): 521-522. Doi: 10.1016/j.annemergmed.2017.06.014

Jun 06, 2018
Podcast # 337: Airway Burn Inhalation
06:30

Author: John Winkler, MD

Educational Pearls:

  • Singed nasal hairs, soot around mouth, hoarse voice, drooling, and burns to head/face are signs suggestive of inhalation injury.
  • Early intubation is critical for these patients as the airway changes rapidly.
  • With inhalation injuries, the upper airway is burned while the lower airway is damaged by inhaled chemicals in the soot and can cause ARDS.
  • Carbon monoxide (CO) and cyanide (CN) poisoning can occur with inhalation injuries.
  • Treatment for CO poisoning is 100% oxygen and possible hyperbarics. Treatment for CN poisoning is cyanocobalamin.

 

References

Rehberg S, Maybauer MO, Enkhbaatar P, et al. Pathophysiology, management and treatment of smoke inhalation injury. Expert Rev Respir Med 2009; 3:283.

Woodson CL. Diagnosis and treatment of inhalation injury. In: Total Burn Care, 4 ed, Herndon DN (Ed), 2009.

 

 

Jun 04, 2018
Podcast # 336: Hypokalemia
03:42

Author: Dylan Luyten, MD

Educational Pearls:

 

  • Most important questions to answer with low potassium are 1. What are their symptoms? 2. Can they take potassium by mouth?
  • Oral repletion is faster, cheaper, and more effective than IV repletion.
  • Give IV potassium when patients have K < 2.5 mmol/L or present with arrhythmias and/or characteristic EKG changes (flattened T waves).
  • Most patients who are hypokalemic are hypomagnesemic and require magnesium supplementation.  Checking a level is unnecessary.

 

References

Ashurst J, Sergent SR, Wagner BJ, Kim J. Evidence-based management of potassium disorders in the emergency department. Emerg Med Pract. 2016 Nov 22;18(Suppl Points & Pearls):S1-S2

 

Whang R, Flink EB, Dyckner T, et al. Magnesium depletion as a cause of refractory potassium repletion. Arch Intern Med 1985; 145:1686.

May 31, 2018
Podcast # 335: Blunt Head Trauma
08:00

Author: Peter Bakes, M.D.

Educational Pearls:

 

  • Epidural hematomas have a characteristic convex appearance on CT while a subdural hematoma will have a concave appearance.
  • Indications for operative intervention for subdural hematoma may include: >5 mm midline shift, over 10 mm in thickness, comatose with ICP >20, or patient neurologic deterioration.

 

References

Bullock, M. R. et. al. . Surgical management of acute subdural hematomas. 2006. Neurosurgery, 58(SUPPL. 3). DOI: 10.1227/01.NEU.0000210364.29290.C9.

Huang KT, Bi WL, Abd-El-Barr M, Yan SC, Tafel IJ, Dunn IF, Gormley WB. The Neurocritical and Neurosurgical Care of Subdural Hematomas. Neurocrit Care. 2016. 24(2):294-307. doi: 10.1007/s12028-015-0194-x.

May 29, 2018
Podcast #334 - Resuscitative Thoracotomy
07:45

Author: Dylan Luyten, MD

Educational Pearls:

 

  • Resuscitative thoracotomies are most commonly used for treatment of cardiac tamponade and to selectively perfuse the brain and heart in setting of hemorrhage control.
  • Resuscitative thoracotomies are indicated in patients with penetrating injuries who lose vitals in the ED or those who had vitals within the last 10 minutes.
  • Do not perform resuscitative thoracotomies on patients who have no signs of life on scene, asystole as their presenting rhythm, or no vitals  > 10 minutes.
  • Resuscitative thoracotomies are not indicated in patients with blunt trauma  unless vitals are present in ED.
  • Do not perform CPR on trauma patients.

 

References:

Karmy-Jones R, Namias N, Coimbra R, et al. (2014).Western Trauma Association critical decisions in trauma: penetrating chest trauma. Journal of Trauma Acute Care Surgery. 77:994.

Seamon MJ, Shiroff AM, Franco M, et al. (2009) Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers. Journal of Trauma. 67:1250.

May 25, 2018
Podcast #333 - TBI Prognosticators
03:02

Author: Michael Hunt, MD

Educational Pearls:

 

  • Studies have shown that patients with decreasing GCS scores have worse outcomes, however GCS of 4 has worse outcome than GCS 3.
  • Alternative scoring system is the GCS-P score which is GCS score - number of non-reactive pupils.
  • GCS3 50% mortality 70% poor outcome at 6 months; GCS-P of 1 had mortality 74% and poor outcome at about 90% at 6 months.
  • GCS-P score is a better prognostic indicator than GCS score.

 

References:

Han J, et al (2014). External validation of the CRASH and IMPACT prognostic models in severe traumatic brain injury. Journal of Neurotrauma. 31(13):1146-52.

Maas AI, et al. (2007). Prognosis and clinical trial design in traumatic brain injury: the IMPACT study. Journal of Neurotrauma.  24(2):232-8.

The CRASH trial management group, & the CRASH trial collaborators. (2001). The CRASH trial protocol (Corticosteroid randomisation after significant head injury) [ISRCTN74459797]. BMC Emergency Medicine, 1, 1. http://doi.org/10.1186/1471-227X-1-1.

May 23, 2018
Podcast #332 - Door To Furosemide Time
02:43

Author: Nick Hatch, MD

Educational Pearls:

 

  • Recent study argues that CHF patients receiving furosemide within 60 minutes of arrival had a lower in-hospital mortality than those receiving it after (2.3% vs. 6.0%, p=0.002).
  • Flaw in study is that there were significant baseline differences between groups.

 

References:

Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. JACC 2017. PMID: 28641794

May 21, 2018
Podcast # 331: Oral Rehydration Therapy (ORT)
04:17

Author: Nick Hatch, MD

Educational Pearls:

 

  • The sodium-glucose cotransporter in the gut is essential for rehydration.
  • Oral rehydration therapies require an equimolar concentration of glucose and sodium to be effective.
  • ORT has saved millions of lives globally.
  • Consider using ORT in patients with dehydration. Especially useful in resource limited settings.

 

References:

Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ. 2000; 78:1246.

Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am. 2018. 36(2):259-273. doi: 10.1016/j.emc.2017.12.004.

May 19, 2018
Podcast # 330: Behcet Disease
04:12

Author: Nick Hatch, MD

Educational Pearls:

 

  • Behcet Disease is an autoimmune disease that can affect any organ system.
  • Typical symptoms include recurrent oral and genital ulcers, but more concerning features include skin rashes, ocular problems, and strokes.
  • Patients with Behcet disease with hypotension should have low threshold for giving steroids.

 

References:

Arlt W, Allolio B. Adrenal insufficiency. Lancet, 2003; 361:1881.

Sakane T, Takeno M, Suzuki N, Inaba G. Behçet's disease. New England Journal of Medicine. 1999; 341:1284.

May 17, 2018
Podcast # 329: Hypokalemic Periodic Paralysis
03:46

Author: Dylan Luyten , MD

Educational Pearls:

 

  • Rare autosomal dominant condition that is often misdiagnosed as a psychiatric illness.
  • Presents as profound muscle weakness with frank paralysis that is often precipitated by vigorous exercise, high carb diet, high sodium load, or by high temperatures.
  • Supplemental potassium can rapidly reverse symptoms.
  • Important to rule out thyrotoxicosis (get a TSH!).
  • Prevention is key: adhering to a low carb and low sodium diet with supplemental potassium can help prevent episodes.

 

References:

Vicart S, Sternberg D, Arzel-Hézode M, et al. Hypokalemic Periodic Paralysis. 2002 Apr 30 [Updated 2014 Jul 31]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1338/?report=classic

 

Statland JM, Fontaine B, Hanna MG, et al. Review of the Diagnosis and Treatment of Periodic Paralysis. Muscle & Nerve. 2018;57(4):522-530. doi:10.1002/mus.26009.

May 15, 2018
Podcast # 328: Sleep Deprivation
05:42

Author: Sam Killian, MD

Educational Pearls:

 

  • Insufficient sleep and disrupted circadian rhythms are a major health problem today

 

  • Millions of dollars, thousands of deaths, and millions of  injuries are related to sleep deprivation every year
  • 56 billion dollars - 24,000 deaths - 2.5 million disabiling injuries related to a sleep-type deprivation
  • Exxon valdez, challanger, chyrnobel linked to sleep deprivation- at least partially
  • Data has shown that in the Spring (when people lose an hour of sleep) there were 8% more traffic accidents on the Monday immediately after daylight savings. Conversely, in the Fall (when people gain an hour of sleep), there were 8% fewer traffic accidents on the Monday immediately after daylight savings.
  • Studies have also shown an increased risk of myocardial infarction in Spring immediately after daylight savings, and a decreased risk of myocardial infarction in the Fall immediately after daylight savings.

References:

Corren S. Traffic Accidents and Daylight Saving Time. New England Journal of Medicine. 1996;335(5):355-357. doi:10.1056/nejm199608013350517

Janszky I, Ljung R. Shifts to and from Daylight Saving Time and Incidence of Myocardial Infarction. New England Journal of Medicine. 2008;359(18):1966-1968. doi:10.1056/nejmc0807104.

May 11, 2018
Podcast # 327: No More Hemoccults
02:52

Author: Don Stader, MD

Educational Pearls:

 

  • The use of fecal occult blood tests is falling out of favor in emergency departments
  • These tests have strong evidence suggesting their efficacy in colon cancer screening but clinical significance in ED is limited
  • They have relatively high false positive and false negative rates
  • Small/microscopic bleeding are often not clinically significant in the ED but can lead to increased costs from over-testing and other harms from fecal occult blood testing

 

References:

Gupta A, Tang Z, Agrawal D. Eliminating In-Hospital Fecal Occult Blood Testing: Our Experience with Disinvestment. American Journal of Medicine. (2018). 10.1016/j.amjmed.2018.03.002

May 09, 2018
Podcast # 326: Valley Fever
03:17

Author: Michael Hunt, MD

Educational Pearls:

  • Valley fever is a fungal infection known as Coccidiomycosis that can present with vague symptoms like cough, fever, myalgias.
  • A thorough history is critical to the diagnosis. Disease is localized to  the Southwestern US (California, New Mexico, Arizona, Nevada, Utah) and parts of Central/South America.
  • Disease is caused by inhaling fungal spores which damage the lung. Rarely, the disease can disseminate and cause infections that require systemic anti fungal therapy.

 

References:

Centers for Disease Control and Prevention (CDC). Increase in reported coccidioidomycosis--United States, 1998-2011. MMWR Morb Mortal Wkly Rep 2013; 62:217.

Saubolle MA, McKellar PP, Sussland D. (2007). Epidemiologic, clinical, and diagnostic aspects of coccidioidomycosis. Journal of Clinical Microbiology. 45:26.

Taylor AB, Briney AK. (1949). Observations on primary coccidioidomycosis. Annals of Internal Medicine. 30:1224.

May 07, 2018
Podcast #325: Vaping and Pneumonia
03:15

Author: Sam Killian, MD

Educational Pearls:

  • Being exposed to E-cigarette vapor may increase risk of pneumonia.
  • Recent study has shown e-cigarette vapor increases quantities of Platelet-activating-receptor factor in epithelial cells, which may aid pneumococcal bacteria in entering pneumocytes.

References:

Miyashita L, et al. (2018). E-cigarette vapour enhances pneumococcal adherence to airway epithelial cells. The European Respiratory Journal. 7;51(2).

 

May 04, 2018
Podcast #324: Superwarfarin
04:03

Author: Rachel Beham, PharmD

Educational Pearls:

  • Some synthetic cannabinoids have been contaminated with Brodifacoum. Brodifacoum is a Vitamin K antagonist and can present with a severe coagulopathy.
  • Brodifacoum is commonly known as “superwarfarin” and has a very long half life of 120+ days.
  • Check PT/INR in patients with a bleeding diathesis in setting of synthetic cannabinoid use.
  • Treatment is activated charcoal and large doses of Vitamin K (10mg Q6H for months).

References:

Lipton R.A.; Klass E.M. (1984). "Human ingestion of a 'superwarfarin' rodenticide resulting in a prolonged anticoagulant effect". JAMA. 252: 3004–3005.

La Rosa F; Clarke S; Lefkowitz J. B. (1997). "Brodifacoum intoxication with marijuana smoking". Archives of Pathology & Laboratory Medicine. 121: 67–69

May 02, 2018
Podcast #323: Calcium Channel Toxicity
07:07

Author: Jared Scott, M.D.

Educational Pearls:

  • Cardiac myocytes and vascular smooth muscle are dependent on an intracellular calcium influx for contraction. Pancreatic beta cells rely on calcium to release insulin.
  • Calcium channel blockers will decrease cardiac contractility and heart rate, but will also cause vascular smooth muscle relaxation with a subsequent decrease in systemic vascular resistance.
  • Resultant cardiac depression and hypotension.
  • Pancreatic beta cells also use calcium to release insulin, so calcium channel blockade can cause hyperglycemia.
  • Treatment for calcium channel toxicity include: fluid resuscitation, calcium gluconate, vasopressors, and high dose insulin.
  • Dosing for insulin therapy is usually 1-5 Units/kg/hr. Make sure to add dextrose!

 

References:

Boyer EW, Shannon M. (2001).Treatment of calcium-channel-blocker intoxication with insulin infusion. New England Journal of Medicine. 344:1721.

Proano L, Chiang WK, Wang RY. (1995).Calcium channel blocker overdose. American Journal of Emergency Medicine. 13:444.

St-Onge M, Dubé PA, Gosselin S, et al. (2014). Treatment for calcium channel blocker poisoning: a systematic review. Clinical Toxicology. 52:926.

 

Apr 30, 2018
Podcast #322: Methemoglobinemia
04:37

Author: Nick Hatch, M.D.

Educational Pearls:

 

  • Methemoglobinemia is when the iron in hemoglobin is in the Fe3+ (ferric) state rather than the normal Fe2+  (ferrous) state. Methemoglobin cannot release oxygen at the tissues.
  • Symptoms include cyanosis, headache, tachycardia, dyspnea, and lethargy.
  • Suspect in setting of hypoxia that does not improve with oxygenation, and clinical cyanosis with a normal PaO2 on ABG.
  • Treatment is methylene blue which reduces the iron back to the ferrous state.
  • Causes can be Dapsone, Lidocaine, Benzocaine.

 

References:

Agarwal N, Nagel RL, Prchal JT. Dyshemoglobinemias. In: Disorders of Hemoglobin: Genetics, Pathophysiology, and Clinical Management, 2nd ed, Steinberg M (Ed), 2009. P.607

Cortazzo JA, Lichtman AD. (2014). Methemoglobinemia: a review and recommendations for management. Journal of Cardiothoracic and Vascular Anesthesia. 28:1043.

Darling R, Roughton F. (1942). The effect of methemoglobin on the equilibrium between oxygen and hemoglobin. American Journal of Physiology. 137:56.

Apr 27, 2018
Podcast #321: Migraine Treatment in ED
03:19

Author: Jared Scott, M.D.

Educational Pearls:

 

  • Recent study compared Compazine with Benadryl vs. Dilaudid for acute migraine management in the ED.
  • Compazine + Benadryl demonstrated migraine relief in 60% of patients compared to the 31% of patients who were relieved with Dilaudid.
  • Compazine + Benadryl is a superior migraine treatment than Dilaudid.

 

References:

Friedman BW, et. al. (2017). Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine. Neurology. 89(20):2075-2082


Apr 25, 2018
Podcast #320: PE in Pregnancy
04:09

Author: Don Stader, M.D.

Educational Pearls:

 

  • Pulmonary embolism is one of the leading causes of maternal mortality.
  • There is disagreement among different medical societies about the value of D-dimer as a screening modality. If you use it, consider the rational D-dimer approach whereby you add 250 to your cut-off for every trimester.
  • A useful screening modality is an ultrasound of bilateral lower extremities looking for DVT.
  • Keep in mind, both a V/Q scan and CT scan have a significant amount of radiation. CTA is probably the right diagnostic test (less radiation than CT w&w/o).
  • Always use the shared decision-making model and clinical acumen to choose your tests.

 

References:

Leung AN, et. al. (2011). An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy. American Journal of Respiratory and Critical Care Medicine. 184(10):1200-8

 

Polak JF, Wilkinson DL. (1991). Ultrasonographic diagnosis of symptomatic deep venous thrombosis in pregnancy. American Journal of Obstetrics and Gynecology. 165(3):625-9.

Sachs BP, et. al. (1987). Maternal mortality in Massachusetts. Trends and prevention. New England Journal of Medicine. 316(11):667-72.

Apr 23, 2018
Podcast #319: Cardiac Arrest Survival Factors
02:16

Author: Aaron Lessen, MD

Educational Pearls:

 

  • Shockable rhythms like V-fib or V-tach have a better prognosis than patients with PEA or asystole.
  • Recent study has shown an initial electrical frequency in PEA between 10-24/min had worse outcomes than PEA with initial rhythm over 60/min.
  • Patients with an initial electrical frequency in PEA over 60/min did just as well as patients with shockable rhythms. Of them, there was a 22% survival rate with 15% having a good neurologic outcome.

 

References:

Weiser, C., et al. (2018). Initial electrical frequency predicts survival and neurological outcome in out of hospital cardiac arrest patients with pulseless electrical activity. Resuscitation. 125:34-38

 

Apr 20, 2018
Podcast #318: Nystagmus
01:57

Author: Erik Verzemnieks, M.D. 


Educational Pearls:

●  Common causes of nystagmus: Congenital disorders, CNS diseases (MS, CVA), Intoxication

●  Drugs associated (ETOH, Ketamine, PCP, SSRI, MDMA, Lithium, Phenytoin, Barbiturates)

●  If a patient has nystagmus and is intoxicated, consider other drugs and etiologies as potential sources

References:
Alpert JN. (1978). Downbeat nystagmus due to anticonvulsant toxicity. ​Annals of

Neurology.​ 4(5):471-3.
Rosenberg, ML. (1987) Reversible downbeat nystagmus secondary to excessive

alcohol intake. ​Journal of Clinical Neuroophthalmology​. 7(1):23-5.

Weiner AL, Vieira L, McKay CA, Bayer MJ. (2000). Ketamine abusers presenting to the emergency department: a case series. ​Journal of Emergency Medicine.​ 18(4):447-51.

Apr 13, 2018
Podcast #317: Elbow Dislocation
02:40

Author: John Winkler, M.D.

Educational Pearls:

●  Lower mechanisms of injury have a lower chance of an associated fracture or major ligament injury

●  One major concern is having a fracture fragment in the joint (can lead to chronic arthritic pain)

●  Evaluation should involve checking the neurovascular status of the arm and reduce the fracture as soon as possible. Immobilize arm in a sling and consult orthopedics if there is intra-articular involvement.

References:

https://orthoinfo.aaos.org/en/diseases--conditions/elbow-dislocation/

Mehta, JA; Bain, GI. (2004). Elbow dislocations in adults and children. ​Clinics in Sports Medicine.​ 23(4):609-27.

Apr 11, 2018
Podcast #316: Abnormalities in Alcohol Intoxication
03:44

Author: Michael Hunt, M.D.

Educational Pearls:

 

  • 1% of patients presenting to ED with alcohol intoxication end up going to the ICU
  • Most common critical illnesses were acute hypoxic respiratory failure, sepsis, and intracranial hemorrhage
  • Predictive markers: Vital abnormalities (hypoxia, tachycardic, tachypneic, hypothermic, hyperthermia, hypoglycemia) and patients receiving parenteral sedatives had higher incidence of ICU admission

 

References:

Klein, LR; et al. (2018). Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication. Annals of Emergency Medicine. 71(3):279-288

Apr 09, 2018
Podcast #315: Retropharyngeal Infections in Pediatrics
06:22

 

Author: Dr. Karen Woolf, MD

Educational Pearls:

  • Anatomy : base of skull to posterior mediastinum, anteriorly bounded by middle layer of deep cervical fascia and posteriorly by the deep layer, communicates to lateral pharyngeal space bounded by carotid sheath. Lymph node chains draining nasopharynx, sinuses, middle ear, etc. run through it.
  • Epidemiology & Microbiology: most common kids 2-4, (neonates too). Polymicrobial (GAS, MSSA, MRSA, respiratory anaerobes).
  • Signs and symptoms can include pharyngitis, dysphagia, odynophagia, drooling, torticollis, muffled voice, respiratory distress, stridor, neck swelling, and trismus.
  • Exam may show drooling, posterior pharyngeal swelling, anterior cervical LAD, or a neck mass.
  • Imaging: Get CT neck w/IV contrast!
  • DDx: epiglottis, croup, bacterial tracheitis, peritonsillar abscess, trauma, foreign body, angioedema, cystic hygroma, meningitis, osteomyelitis, tetanus toxin.
  • Tx: Unasyn, if not responding add Vancomycin or Linezolid; surgical drainage if airway is compromised.
  • Complications: airway obstruction, sepsis, aspiration pneumonia, IJ thrombosis, carotid artery rupture, mediastinitis.

 

References:

Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics 2003; 111:1394.

Fleisher GR. Infectious disease emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.783.

Goldstein NA, Hammersclag MR. Peritonsillar, retropharyngeal, and parapharyngeal abscesses. In: Textbook of Pediatric Infectious Diseases, 6th ed, Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL (Eds), Saunders, Philadelphia 2009. P.177

Apr 06, 2018
Podcast #314: Psychogenic nonepileptic seizures (PNES)
05:02

Author: Gretchen Hinson, M.D.

Educational Pearls:

 

  • PNES vs. epilepsy: postictal state is diagnostic of an epileptic seizure (sonorous respirations and/or confusion, lasting typically 20-30 minutes); Epileptiform seizures show decrease in convulsion frequency, but increase in convulsion amplitude while PNES convulsions demonstrate episodic convulsion amplitudes; and epileptiform seizures usually do not pause.
  • PNES is a form of conversion disorder and can be associated with underlying personality disorder; however there are patients with epilepsy that also can have PNES which complicates the diagnosis and treatment. 
  • Patients that are malingering may have flailing movements and might talk during the episodes - both not typical of epileptic seizures or PNES.
  • Treatment for PNES is with psychotropic medications and psychotherapy as opposed to antiepileptic medications

 

References:

Avbersek, A; Sisodiya, S. (2010). Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?.  Journal of neurology, neurosurgery, and psychiatry. 81(7):719-25.

Devinsky, O; Gazzola, D; LaFrance, W. Curt (2011). Differentiating between nonepileptic and epileptic seizures. Nature Reviews. Neurology. 7 (4): 210–220.

Lesser, RP. (2003). Treatment and Outcome of Psychogenic Nonepileptic Seizures. Epilepsy Currents. 3(6):198-200. doi:10.1046/j.1535-7597.2003.03601.x.

Pillaia, JA; Hautab SR. (2012). Patients with epilepsy and psychogenic non-epileptic seizures: An inpatient video-EEG monitoring study. Seizure. 21(1): 24-27.


Apr 04, 2018
Podcast #313: Flu Screening
07:22

Author: Dr. Peter Bakes

Educational Pearls:

  • High risk patients: underlying lung disease, immunocompromised, extremes of age (<2 or >65), underlying cardiac/renal/neurologic disease, and pregnant women
  • Testing: RT-PCR (RNA based test that is both sensitive and specific)
  • Workup: comorbidities dictate whether or not they are screened; CXR indicated in high risk patients with respiratory symptoms
  • Morbidity from flu comes from secondary pneumonia, sepsis, and septic shock
  • Treatment options are Tamiflu and Relenza (Relenza is contraindicated in patients with lung disease)
  • High risk patients see average of 2.5 days shortening of illness and a decrease in illness severity. Low risk patients see average of 1.5 days shortening of illness.

References:

https://www.cdc.gov/flu/about/disease/high_risk.htm

Binnicker MJ, Espy MJ, Irish CL, Vetter EA. Direct Detection of Influenza A and B Viruses in Less Than 20 Minutes Using a Commercially Available Rapid PCR Assay. J Clin Microbiol. 2015 Jul; 53(7): 2353-4.

Longo, Dan L. (2012). "187: Influenza". Harrison's principles of internal medicine (18th ed.). New York: McGraw-Hill. ISBN 9780071748896.

Apr 02, 2018
Podcast #312: SCIWORA
04:44

Author: Sam Killian, M.D.

Educational Pearls:

 

  • Spinal cord injury without radiographic abnormality (SCIWORA) is a diagnosis defined as traumatic injury to spine with clinical sx of traumatic myelopathy (paraplegia, paresthesias, FND) without radiographic abnormalities.
  • Term was established in  1970’s before MRI and accounted for about 15% of injuries at the time (mainly children). Today SCIWORA accounts for about 10% of spinal injuries.
  • Belief is that injury causes subtle movement of the spinal cord from its natural position with resultant contusion or ischemia with subsequent deficits.
  • Treatment involves prolonged immobilization (up to 12 weeks).

 

References:

Walecki, J. (2014). Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) – Clinical and Radiological Aspects. Polish Journal of Radiology,79, 461-464. doi:10.12659/pjr.890944

Mar 30, 2018
Podcast #311: Recurrence of Seizures in Pediatrics
02:21

Author: Aaron Lessen, M.D.

Educational Pearls:

  • Recurrence rate for first time unprovoked seizures - 5% after 48 hours, 14% at 2 weeks , 30% after 4 months.
  • Higher risk for recurrence: age under 3; patients with multiple seizures at initial presentation, focal neurologic findings on initial presentation.
  • Useful for counseling patients and recommending follow up.

References:

Shinnar S, Berg AT, Moshé SL, et al. Risk of seizure recurrence following a first unprovoked seizure in childhood: a prospective study. Pediatrics 1990; 85:1076.

Mar 28, 2018
Podcast #310: Bicarb in DKA
05:08

Author: Gretchen Hinson, M.D.

Educational Pearls:

  • Controversial topic.
  • Pathophysiology - acidosis leads to an extracellular potassium shift. Patients in DKA will be intracellularly potassium deplete, but will have a falsely normal/elevated serum potassium.
  • 3 risk of giving bicarb in DKA - alkalosis will drive potassium intracellularly but can overshoot (hypokalemia) and  increase risk of arrhythmias; bicarb slows clearance of ketones and will transiently increase their precursors; bicarb can cause elevated CSF acidosis.
  • 3 instances when appropriate to give bicarb in DKA: DKA in arrest; hyperkalemic in DKA with arrhythmia; fluid and vasopressor refractory hypotension.


References:

Bratton, S. L., & Krane, E. J. (1992). Diabetic Ketoacidosis: Pathophysiology, Management and Complications. Journal of Intensive Care Medicine, 7(4), 199-211. doi:10.1177/088506669200700407

Chua, H., Schneider, A., & Bellomo, R. (2011). Bicarbonate in diabetic ketoacidosis - a systematic review. Annals of Intensive Care, 1(1), 23. doi:10.1186/2110-5820-1-23

Mar 26, 2018
Podcast #309: Return Visits to the ED for UTI
02:27

Author: Alicia Oberle, MD

Educational Pearls:

 

  • Recent study has shown risk factors for return included patients at high risk for resistance (nursing home, obstructive uropathy), patient where diagnogsis of pyelonephritis was missed, but the biggest risk factor was the existence of bug-drug mismatches.
  • Cephalexin (Keflex) was associated with highest rate of return, while nitrofurantoin (Macrobid) was associated with lowest return rate.
  • Recommendation is to continue to detect between pyelonephritis and cystitis, broaden coverage for patients with complications, and utilize your facilities antibiogram.

 

References:

Jorgensen S, et al. ( 2018). Risk factors for early return visits to the emergency department in patients with urinary tract infection. American Journal of Emergency Medicine. 36(1):12-17

 

Mar 23, 2018
Podcast #308: Ultrasound in Cardiac Arrest
02:42

Author: Aaron Lessen, M.D.

Educational Pearls:

  • There is currently debate within the medical community about what constitutes cardiac activity on ultrasound in the setting of cardiac arrest. A recent study has shown there providers looking at the same clips from an echo will disagree about what constitutes cardiac activity.
  • Some of the confusion stems from movement that is not cardiac in etiology. For example, some alvular movement can be due to IV fluids and some cardiac motion can be due to the patient being bagged.
  • Cardiac activity is defined as “Any intrinsic motion of the myocardium.” However, even if this is present, it is important to ask if it clinically significant cardiac activity.
  • Despite disagreement, ultrasound can be useful for clinical decision making.

 

References:

Gaspari R et al. (2016) Emergency Department Point-Of-Care Ultrasound in Out-Of-Hospital  and in-ED Cardiac Arrest. Resuscitation; 109: 33 – 39.

Hu K et al. (2017) Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med.


Mar 21, 2018
Podcast #307: Guillain-Barre Syndrome
04:35

Author: Peter Bakes, M.D.

Educational Pearls:

 

  • Rare disease with 1-2 patients out of 100,000. About 60% of patients report a preceding diarrheal illness and classically presents with an ascending motor weakness.
  • Pathophysiology is likely due to molecular mimicry where the immune system creates antibodies against a pathogen (C. jejuni ) which appears similar to the myelin of peripheral nerves resulting in autoimmune demyelination.
  • Diagnosis is made by clinical presentation +/- a spinal tap with a characteristic high protein count but without cells.
  • Treatment is IVIG or plasmapharesis. It is important to monitor respiratory function because about 15% of patients progress to respiratory failure.

 

References:

Sejvar, James J.; Baughman, Andrew L.; Wise, Matthew; Morgan, Oliver W. (2011). "Population incidence of Guillain–Barré syndrome: a systematic review and meta-analysis"

van den Berg, Bianca; Walgaard, Christa; Drenthen, Judith; Fokke, Christiaan; Jacobs, Bart C.; van Doorn, Pieter A. (15 July 2014). "Guillain–Barré syndrome: pathogenesis, diagnosis, treatment and prognosis". Nature Reviews Neurology. 10 (8): 469–482.

Yuki, Nobuhiro; Hartung, Hans-Peter (14 June 2012). "Guillain–Barré Syndrome". New England Journal of Medicine. 366 (24): 2294–2304.

Mar 19, 2018
Podcast #306: Tramadol Drama
03:17

Author: Nick Hatch, M.D.

Educational Pearls

  • Tramadol acts at multiple receptors and is a partial agonist at the mu opioid receptor, but also blocks reuptake of serotonin and norepinephrine throughout the body among others.

 

  • One major side effect to be aware of is that it lowers the seizure threshold.
  • Useful in setting of pain control in patients with contraindications to NSAIDs who are poor opioid candidates.
  • Use with caution as it potential for abuse.

 

References

Hennies HH, Friderichs E, Schneider J (July 1988). "Receptor binding, analgesic and antitussive potency of tramadol and other selected opioids". Arzneimittel-Forschung. 38 (7): 877–80.

"Tramadol Hydrochloride". The American Society of Health-System Pharmacists. Retrieved Dec 1, 2014.

"Withdrawal syndrome and dependence: tramadol too". Prescrire Int. 12 (65): 99–100. 2003

Mar 16, 2018
Podcast #305: Stuffers vs. Packers : Drug-Packet Ingestion
03:25

Author: Aaron Lessen, M.D.

Educational Pearls

  • A “stuffer” is a term for someone who hastily and conceals a bag of drugs orally/rectally/vaginally in an unplanned situation. A “packer” is someone who is planning to smuggle drugs, and does so in a similar manner.

 

  • “Stuffers”are more likely to have the drug container open up in their system, while packers tend to have more reliable containment, but typically have larger quantities on-board.
  • Be on look out for symptoms associated with the drug’s exposure (drug dependent) as well as mechanical symptoms (perforation; obstruction).
  • If suspicious, order CT as X-rays underestimate severity.
  • Management: treat symptoms of intoxication appropriately, observe if packets are intact, consider surgery/endoscopy if necessary.

 

References

Dueñas-Laita A, Nogué S, Burillo-Putze G (2004). "Body packing". New England Journal of Medicine. 350 (12): 1260–1

Hergan K, Kofler K, Oser W (2004). "Drug smuggling by body packing: what radiologists should know about it". Eur Radiology. 14 (4): 736–42.

Traub SJ, Hoffman RS, Nelson LS (2003). "Body packing—the internal concealment of illicit drugs". New England Journal of Medicine. 349 (26): 2519–26.

Mar 14, 2018
Podcast #304: Nostalgia
05:27

Author: Dylan Luyten, MD

Educational Pearls

 

  • Johannes Hoffer coined term Nostalgia in 1688 in his medical dissertation.

 

  • Nostalgia was a formal medical diagnosis, and one that dates back to 17th century when soldiers had longing for home and melancholy with a constellation of symptoms including lethargy, sadness, disturbed sleep, heart palpitations, GI complaints, and/or skin findings for which the only cure was to return home.

 

  • In the civil war, over 5000 soldiers were given medical leave for nostalgia.
  • Always remember to view your patient in the appropriate context (psychosocial, cultural, historical, etc.)

 

References

Beck, J. (2013, August 14). When Nostalgia Was a Disease. Retrieved March 08, 2018, from https://www.theatlantic.com/health/archive/2013/08/when-nostalgia-was-a-disease/278648/

Mar 12, 2018
Podcast #303: Lazarus Effect
03:51

Author: Dylan Luyten, M.D.

Educational Pearls

  • The Lazarus phenomenon is the delayed return of spontaneous circulation after cessation of CPR.
  • A prospective study in Finland found 5 out of 840 patients where CPR was attempted in the setting of cardiac arrest experienced the Lazarus effect (about 0.6%).
  • 3 of these patients died on scene, and the other 2 died in the hospital at 1.5 and 26 hours respectively.
  • Ultimately, the Lazarus effect is rare, but it does occur and providers and family members should be aware that signs such as gasping or twitching may be seen after cardiac arrest, but the prognosis is still dismal.

References

Kuisma, M, et al. (September 2017) “Delayed return of spontaneous circulation (the Lazarus phenomenon) after cessation of out-of-hospital cardiopulmonary resuscitation”. Resuscitation. 118: 107-111

 

Mar 09, 2018
Podcast #302: Flu
03:18

Author: Jared Scott, M.D.

Educational Pearls

  • Flu is widespread throughout the US (through Jan 20th 2018).
  • All age groups have seen surge in hospitalizations, but 65 + age group has seen the largest surge in hospitalizations due to flu.
  • New recommendations for treating with Tamiflu! Treat the following high-risk groups at any stage of illness:  Children under age 2, Adults 65 and older, patients with comorbidities such as chronic lung disease, heart disease, blood disorders, kidney disorders, liver disorders, neurological disorders, immunosuppressed, pregnant women, American Indians, extreme obesity, women under 19 on long-term aspirin, and nursing home residents.

References:

https://www.cdc.gov/flu/about/disease/high_risk.htm

https://www.cdc.gov/flu/weekly/summary.htm

Mar 07, 2018
Podcast #301: Biliary Pathology
03:50

Author: Don Stader, M.D.

Educational Pearls

  • Common pathologies include cholecystitis, choledocholithiasis, and in concerningly ascending cholangitis.
  • Cholecystitis is obstruction at the cystic duct leading to inflammation of gallbladder wall, while choledocholithiasis is a distal obstruction of the biliary tree, and ascending cholangitis is an ascending infection of the biliary tree secondary to obstruction.
  • Risk factors for Cholecystitis are the 5 F’s (Fat, Forty, Female, Fertile, Family Hx).
  • Classic symptoms seen in ascending cholangitis are Charcot’s Triad of fever, RUQ pain, and jaundice, or Reynold’s pentad which is more severe and has the addition of
    altered mental status and hypotension.
  • Porcelain gallbladder is a radiographic finding showing calcification of the gallbladder that is associated with cancer of the gallbladder.

References:

Kimura Y, Takada T, Kawarada Y, et al. (2007). "Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg.

Strasberg, SM (26 June 2008). "Clinical practice. Acute calculous cholecystitis". The New England Journal of Medicine. 358 (26): 2804–11.

Mar 05, 2018
Opioid Safety Summit: Admiral Winnefeld's Strategy to Wage War on the Opioid Epidemic
0

Since the tragic overdose of his son, Admiral Winnefeld has developed an intriguing strategy on how to combat the Opioid Epidemic. 

Feb 27, 2018
Dreamland in Denver Part VI: "Dreamland"
43:27

Sam Quinones, American journalist and author of the critically acclaimed book, Dreamland: The True Tale of America's Opiate Epidemic, shares the story of how he discovered the truth about the Opiate Epidemic. 

Feb 16, 2018
Dreamland in Denver Part V: "Tales from a Harm Reductionist"
10:17

Lisa Raville, executive director of The Harm Reduction Action Center in Denver, shares tales from her perspective as a Harm Reductionist. 

Feb 16, 2018
Dreamland in Denver Part IV: "Doing Harm: Medicine’s Role in Creating the Opioid Crisis."
19:48

Emergency Medical Minute's very own Donald Stader, MD explains Medicine's contribution to the catastrophe that is the Opioid Epidemic. 

Feb 16, 2018
Dreamland in Denver Part III: "Opioid Mythbusters: 10 Fallacies that Fueled the Opiate Crisis"
19:16

Dr. Robert Valuck, director of the Colorado Consortium, presents 10 fallacies that have fueled the Opioid Epidemic. 

Feb 16, 2018
Dreamland in Denver Part II: "Why Calling it 'the Opioid Epidemic' Misses the Point
0

The Honorable Alby Zweig shares his impactful first-hand experience with addiction, recovery and triumph.

Feb 16, 2018
Dreamland in Denver Part I: "No Family is S.A.F.E. ...Yet"
18:34

Admiral James Winnefeld and Mary Winnefeld speak publicly for the first time about the tragic overdose of their son, Jonathon, and how 'No Family is S.A.F.E...yet'. 

Feb 16, 2018
Podcast #300: Probiotics
07:03

Author: Peter Bakes, M.D.

Educational Pearls

  • Probiotics are living bacteria that are taken as an oral supplement.
  • Most of the data to support their use is in the prevention of antibiotic-related diarrhea and the reduction of the symptoms of ulcerative colitis (UC).
  • Some studies have some a reduction of the incidence of antibiotic-related diarrhea in children of up to 12% with the use of probiotics.
  • There may be a reduction of up to 60% in the incidence of antibiotic-related C. diff infection in adults with probiotic use
  • Studies have shown a 10% or more reduction in the duration and severity of the symptoms of UC with probiotic use.
  • Proposed mechanisms of probiotics include a decrease in gut permeability and a decrease in pathogenic gut bacteria due to resource competition.

References: http://www.cochrane.org/CD006095/IBD_use-probiotics-prevent-clostridium-difficile-diarrhea-associated-antibiotic-use

Feb 07, 2018
Podcast #299: Black Death, Lice, Math, and Pottery
03:55

Author: Chris Holmes, M.D.

Educational Pearls

  • It’s estimated that about 25 million people died during the Black Plaque. Researchers have confirmed this number by assessing how much old, broken pottery was buried in front of homes and churches from that time period.
  • Traditional thinking has been that the Black Plague was spread primarily by flea bites. However, using mathematical modeling, researchers have theorized that person-to-person spread was more common.

References: https://www.washingtonpost.com/news/speaking-of-science/wp/2016/05/24/broken-pottery-reveals-the-sheer-devastation-caused-by-the-black-death/

Feb 06, 2018
Podcast #298: Seizures
03:28

Author: Sam Killian, M.D. 

Educational Pearls

  • The availability of antiepileptic treatment has changed in the last 30 years.
  • A recent study in JAMA followed 18,000 pts with epilepsy for 30 years to assess the effectiveness of looked at seizure control.
  • The study found that although there have been new drugs introduced over the last 30 years, there has not been much of an improvement in seizure control.
  • Side effect profiles and medicine compliance may have improved in this time period, but the main goal of reducing seizure frequency has not been reached.

References: Chen Z, Brodie MJ, Liew D, Kwan P. Treatment Outcomes in Patients with Newly Diagnosed Epilepsy Treated With Established and New Antiepileptic DrugsA 30-Year Longitudinal Cohort Study. JAMA Neurol. Published online December 26, 2017. doi:10.1001/jamaneurol.2017.3949

Feb 02, 2018
Podcast #297: Truvada
04:14

Educational Pearls

  • Truvada (Emtricitabine/tenofovir) is a combination nucleotide reverse transcriptase inhibitor that can be used as pre-exposure prophylaxis (PrEP) for HIV. It has been shown to dramatically reduce the risk of contracting HIV.
  • It is used in high-risk patients, like the MSM community or those who are in a relationship with someone with HIV.
  • Side effects include nausea, vomiting, headache, and liver damage.
  • HIV testing should be performed every 3 months while taking it, since it is not meant to fight an actual infection.
  • Since 2012, there have only been 3 confirmed cases of transmission while using Truvada.
  • It costs between 50-60$ dollars per pill, but it is covered by most insurances, including Medicaid.
  • Generic version has recently been FDA approved.

References: https://www.cdc.gov/hiv/pdf/prep_gl_patient_factsheet_truvada_english.pdf

Jan 31, 2018
Podcast #296: Synthetic Cannabinoids
05:12

Author: Rachael Duncan, PharmD

Educational Pearls

  • A NEJM study report in July 2016 discussed a situation in New York during which 30 people became “zombie-like” after ingesting synthetic cannabinoids (aka “Spice).
  • The ER managed to coordinate with the CDC to evaluate  blood samples from 18 patients who were transported to the hospital.
  • Of those who went to the ER, the mean age was 36.8, many  of them were homeless, all of them were male. Mass spectrometry was used to confirm the presence of synthetic cannabinoid in their blood.
  • Compared to normal THC, synthetic cannabinoids have a much lower EC50 and LD50.
  • Spice intoxication presents in a variety of ways -patients may be hyperthermic, combative, delirious and/or seizing.
  • Treatment  is supportive, including fluids, cooling, electrolyte management, and sedatives.

References: Adams, A. J., Banister, S. D., Irizarry, L., Trecki, J., Schwartz, M., & Gerona, R. (2017). “Zombie” Outbreak Caused by the Synthetic Cannabinoid AMB-FUBINACA in New York. New England Journal of Medicine, 376(3), 235-242. doi:10.1056/nejmoa1610300

Jan 29, 2018
Podcast #295: UTI
04:15

Author: Sam Killian, M.D.

Educational Pearls

  • Traditionally, UTI diagnosis has been dependent on urine culture, urinalysis and clinical symptoms. But a recent study casts some doubt on the utility of urine cultures.
  • A study in the Journal of Clinical Microbiology did urine cultures and E. coli PCR in 220 women with UTI symptoms and 86 women without UTI symptoms.
  • In the symptomatic women, 67% had positive E. Coli PCR and 98% had a pathogenic bacteria in their urine culture.
  • In the asymptomatic women, 10% had positive E. coli PCR and/or urine culture.
  • Therefore, this study suggests that urine culture may be of limited utility, since symptoms alone seemed to predict bacteriuria.

References: Burd EM, Kehl KS. A Critical Appraisal of the Role of the Clinical Microbiology Laboratory in the Diagnosis of Urinary Tract Infections. Journal of Clinical Microbiology. 2011;49(9 Supplement). doi:10.1128/jcm.00788-11.

Jan 26, 2018
Podcast #294: Rhabdomyolysis
03:33

Author: Michael Hunt, M.D.

Educational Pearls

  • Rhabdomyolysis is caused by the destruction of skeletal muscle that leads to the release of myoglobin, which causes renal failure. It presents with pain and weakness in the affected muscle, as well as dark urine.
  • Diagnosis is made with creatinine kinase levels
  • It can happen to extreme athletes after competition, but the most common presentation is in people who fall and are immobilized for long periods of time.
  • Other causes include burns, crush injuries, viral infections (influenza), bacterial infections (Legionella), and medications (statins in adults, propofol in kids)
  • Treatment is aggressive fluids

References: Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis – an overview for clinicians. Critical Care. 2005;9(2):158-169. doi:10.1186/cc2978.

Jan 22, 2018
Podcast #293: Transient Global Amnesia
04:17

Author: Sam Killian, M.D.

Educational Pearls

  • Transient global amnesia is a paroxysmal, transient memory issue. Remote and immediate memory is preserved, but new memories cannot be made.
  • Patients will have a normal neurological exam and usually no other complaints.
  • The episode will last less than 24 hours, but they usually resolve after 1-2 hours.
  • This is relatively common. It happens in 5/100000 people, mostly men over 50. Recurrence is rare.
  • There is no known cause, but it is associated with migraines and classically occurs after heavy physical exertion or emotional stress.
  • Workup includes  a full neuro exam, imaging for ongoing symptoms, and labs to rule out other causes.
  • Patients can be sent home with reassurance after symptoms resolve. Instruct them to follow up with neurology. Patients with continuing symptoms should be admitted.

References:  Owen D, Paranandi B, Sivakumar R, Seevaratnam M. Classical diseases revisited: transient global amnesia. Postgraduate Medical Journal. 2007;83(978):236-239. doi:10.1136/pgmj.2006.052472.

Jan 19, 2018
Podcast #292: Hypercalcemia
02:42

Author: John Winkler, M.D. 

Educational Pearls

  • Normally, the parathyroid is the master regulator of serum Ca levels. It secretes PTH, which stimulates calcium uptake from the bone and gut.
  • Causes of hypercalcemia include: parathyroid tumor, lytic bone lesions (multiple myeloma), breast cancer, renal injury, and some lung cancers.
  • Hypercalcemia can lead to poor bone quality and pathological fractures. It can also cause heart arrhythmias.
  • It is important to order an ionized calcium to quantify the level of hypercalcemia, since calcium binds to albumin.
  • Treatment for hypercalcemia includes fluids and loop diuretics.

References:  https://emedicine.medscape.com/article/766373-treatment

Jan 17, 2018
Podcast #291: Cincinnati Stroke Scale
02:19

 Author: Nick Hatch, M.D.

Educational Pearls

  • The Cincinnati Stroke Scale uses 3 measures to screen for ischemic stroke. The measures are: facial asymmetry, speech quality and arm drift.
  • This scale is used commonly in EMS systems as a screening tool.
  • Studies show that having one out of the 3 elements correlates with a 72% chance of having an ischemic stroke, while having all 3 of the elements correlates with an 85% chance. Overall the scale is highly sensitive but not very specific  (92% and 48%, respectively, in one study).
  • The measures focus on anterior circulation function, and often misses posterior circulation strokes.
  • The Cincinnati Stroke Scale is good for EMS, but not necessarily for emergency physicians.

References:  http://onlinelibrary.wiley.com/store/10.1002/9781118783467.app5/asset/app5.pdf?v=1&t=jcf2yn71&s=3c2341ba472c1fcc88003dc0af7eac28691dd980

Jan 15, 2018
Podcast #290: The Biochemistry of DKA
06:48

Author: Dave Rosenberg, M.D.

Educational Pearls

  • DKA commonly causes hyperkalemia, leading to peaked T-waves on ECG. However, DKA causes hypokalemia at the same time.
  • In DKA, glucose cannot be taken into the cells. This signals the body to create and use acidic ketones for energy. This leads to acidosis. To compensate for increased acid, H ions are pumped into cells. To maintain electroneutrality, K is pumped out of the cell. At the kidney, K is lost in the urine.
  • Overall, while serum K is high in DKA, total body K is low. The derangement in K can lead to life-threatening arrhythmias.
  • Treatment for DKA can induce hypokalemia, as the K will shift back into the cells with insulin administration. Therefore, treatment for DKA needs to include K.

References:  http://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/diabetic-ketoacidosis-dka

Jan 12, 2018
Podcast #289: Cannabinoid Hyperemesis
03:22

Author: Dylan Luyten, M.D.

Educational Pearls

  • Cannabinoid Hyperemesis syndrome is a relatively new diagnosis that presents with vomiting and abdominal pain without a clear etiology in the setting of daily marijuana use.
  • The pathophysiology is not well-understood well, but may involve cannabinoid receptors in the gut.
  • Treatment is abstinence from marijuana, fluids, dextrose, and antiemetics (haldol, ondansetron, etc). Opioids should be avoided.
  • Capsaicin cream on the abdomen may be helpful, as it can distract from the pain and vomiting. Milk can be used to reverse its effects.

References:  Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid Hyperemesis Syndrome. Current drug abuse reviews. 2011;4(4):241-249.

Jan 10, 2018
Podcast #288: Diarrhea
07:15

Author: Peter Bakes, M.D.

Educational Pearls

  • Chronic diarrhea is defined as 3 or more loose, watery stools lasting more than 2-3 weeks.
  • Look for clues in the history, including  travel (could suggest infectious etiology), antibiotic use (could suggest C. Diff), and family history.
  • Irritable Bowel Disease (Crohn’s/Ulcerative Colitis) is an autoimmune disorder that affects 1.3 million Americans and is a leading cause of chronic diarrhea.
  • Crohn’s always involves the terminal ileum, but can present anywhere along the GI tract. It causes transmural inflammation of the bowel wall and can lead to adhesions, perforations, and fistulas. Ulcerative colitis usually involves the rectum and causes mucosal inflammation only.
  • Workup for IBD includes colonoscopy and tissue biopsy.
  • Treatment for IBD includes dietary changes, 5-ASA/Mesalamine, steroids, and infliximab (anti-TNF alpha).

References:  https://www.aafp.org/afp/2011/1115/p1119.html

Jan 08, 2018
Podcast #287: Sepsis Bundles
02:01

Author: Aaron Lessen, M.D.

Educational Pearls

  • Treatment “bundles” are a popular approach to the rapid resuscitation of septic patients. A recent study in New York, where sepsis bundles are mandatory, sought to figure out which aspects of the bundle had impacts on mortality.
  • In a study of 40,000 septic patients, the study found that early antibiotics were associated with better outcomes, while early IV fluids were not associated with better outcomes.
  • This study affirms the important role of early antibiotics in sepsis. IV fluids may play an important role in the treatment of sepsis in some patients, but its role is less clear than antibiotics.

References:  Time to Treatment and Mortality during Mandated Emergency Care for Sepsis Christopher W. Seymour, M.D., Foster Gesten, M.D., Hallie C. Prescott, M.D., Marcus E. Friedrich, M.D., Theodore J. Iwashyna, M.D., Ph.D., Gary S. Phillips, M.A.S., Stanley Lemeshow, Ph.D., Tiffany Osborn, M.D., M.P.H., Kathleen M. Terry, Ph.D., and Mitchell M. Levy, M.D. N Engl J Med 2017; 376:2235-2244 June 8, 2017 DOI: 10.1056/NEJMoa1703058

Jan 05, 2018
Podcast #286: Coronary Vascular Conditions that aren’t STEMI
04:13

Author: Don Stader, M.D.

Educational Pearls

  • While we usually associate the coronary vasculature with STEMIs, there are other pathologies that can affect the heart’s blood supply.
  • Kounis syndrome: an allergic vasospasm of the coronary arteries. This can happen post anaphylaxis or be caused by a stent allergy. It is best treated with aggressive management of the allergic reaction.
  • Kawasaki disease: An autoimmune condition that presents in kids as conjunctivitis, lymphadenopathy, hand/foot swelling, rash, and fever. It can also cause coronary aneurysms, which can rupture and be rapidly fatal.  
  • Prinzmetal angina: Caused by coronary vasospasm. Presents with transient chest pain at rest. Treat with CCBs.
  • Cocaine: Causes coronary vasospasm. Cocaine-induced vasospasm is best treated with BZDs.
  • Coronary artery dissection: increased risk in pregnant women and those with connective tissue disorders.

References:  Memon S, Chhabra L, Masrur S, Parker MW. Allergic acute coronary syndrome (Kounis syndrome). Proceedings (Baylor University Medical Center). 2015;28(3):358-362.

Jan 03, 2018
Podcast #285: C Diff
02:37

Author: Aaron Lessen, M.D. 

Educational Pearls

  • While C. difficile infections are generally thought of as nosocomial, there is a subset of patients who acquire the infection in the community.
  • One recent study showed that about 10% of patients presenting to the ED with diarrhea and without vomiting had a C. diff infection.
  • Another study found risk factors for community-acquired C. diff included recent ED/Urgent care visits and antibiotic use. However, 36% of the patients in that study had no identifiable risk factors.

References:  Gupta A, Khanna S. Community-acquired Clostridium difficile infection: an increasing public health threat. Infection and Drug Resistance. 2014;7:63-72. doi:10.2147/IDR.S46780.

Jan 01, 2018
Podcast #284: Plane Emergencies
03:36

Author: Erik Verzemneicks, M.D.

Educational Pearls

  • 1/600 flights has an on-board request for medical assistance.
  • Most common complaints on board include: syncope, respiratory complaints, and GI complaints. Most of the time, these are exacerbations of underlying chronic conditions.
  • Except for situations involving gross negligence, the Aviation Assistance Act protects providers from legal action as long as they are acting within their scope of practice.
  • Flight crew are CPR and AED trained.
  • The onboard medical kit includes: epinephrine, dextrose, nitroglycerin, NSAIDs, injectable antihistamine, antiemetic, steroids, beta-blocker,  aspirin, stethoscope, BP cuff, airway tools, thermometer and more.
  • There is ground-based medical control for consult and guidance.

References: https://www.acep.org/Clinical---Practice-Management/Emergency-at-30,000-Feet---What-You-Can-Do/#sm.0001eqpidqrpoczltzg1epg0m0aqu

Dec 29, 2017
Podcast #283: Snow Blindness
03:09

Author:  John Winkler, M.D.

Educational Pearls

  • Photokeratitis is a UV burn of the sclera and cornea, which can cause blindness.
  • UV light causes eyelid swelling with diffuse scarring of the eye (widespread, punctate uptake of fluorescein dye). While this can eventually heal, it is incredibly painful.
  • Snow reflects light underneath sunglasses, so wrap-around goggles are the best form of prevention.
  • This can happen to welders, sunbathers or any other person with prolonged UV light exposure. 

References: https://emedicine.medscape.com/article/799025-treatment

Dec 27, 2017
Podcast #282: EKG Changes in DKA
03:57

Author: Dave Rosenberg, M.D.

Educational Pearls

  • EKG changes that can be seen in DKA include ST elevation and peaked T-waves secondary to derangements in K levels.
  • In DKA,  serum K is high, but total body K is low, which can cause said EKG abnormalities.
  • Many things cause ST elevation besides MI, so think beyond STEMI.
  • When someone in in DKA, think about the “Three I’s” for underlying cause: (not taking) insulin, ischemia, infection.

References:  Nageswara Rao Chava. ECG in Diabetic Ketoacidosis. Arch Intern Med. 1984;144(12):2379–2380. doi:10.1001/archinte.1984.00350220101022

Dec 25, 2017
Deep Dive #8: Wintertime Wilderness Medicine
29:50

Author: John Winkler, M.D.

Dr. Winkler shares his knowledge of wilderness medicine and provides insight on how to prevent and treat conditions such as hypothermia, frostbite and sun blindness. More importantly, he gives us tips on how to stay safe while doing our favorite wintertime activities!

Dec 18, 2017
Podcast #281: Intracranial Hemorrhage Treatment
02:34

Podcast #281: Intracranial Hemorrhage Treatment

Author: Don Stader, M.D.

Educational Pearls

  • Types of traumatic bleeds include subdural, epidural, and subarachnoid.
  • Treatment for a traumatic bleed includes maintenance of systolic BP above 120 and seizure prophylaxis with phenytoin.
  • In atraumatic bleeds, treatment should focus on lowering  blood pressure to reduce bleeding.

References: https://www.aliem.com/2017/09/intracranial-hemorrhage-management/

Dec 15, 2017
Podcast #280: Isolated Aphasia in Stroke
01:24

Author: Aaron Lessen, M.D.

Educational Pearls

  • Patients with an ischemic stroke from occlusion of the left middle cerebral artery often present with aphasia in addition to other neurological deficits.
  • A recent study looked at patients presenting with suspected stroke. Of the 700 patients recruited, 3% had isolated aphasia on exam.  On follow-up, none of the 3% had evidence of stroke on imaging. Underlying causes of the isolated aphasia in these patients included syncope, infections, seizures were the underlying cause.  

References: Gabriel Casella, Rafael H. Llinas, Elisabeth B. Marsh, Isolated aphasia in the emergency department: The likelihood of ischemia is low, Clinical Neurology and Neurosurgery, Volume 163, 2017, Pages 24-26, ISSN 0303-8467, https://doi.org/10.1016/j.clineuro.2017.10.013.

Dec 11, 2017
Podcast #279: Sedation After Intubation
01:56

Author: Aaron Lessen, M.D.

Educational Pearls

  • Post-intubation care should always include pain control and adequate sedation.
  • Commonly used sedation agents include propofol, ketamine and versed.
  • However, too much sedation is harmful. Deep sedation (RASS -4 to -5)  is associated with worse long-term outcomes. RASS of 0 to -2 is ideal, as long as the patient is comfortable.

References: https://coreem.net/core/post-intubation/

Dec 08, 2017
Podcast #278: Subdural Hematomas
02:41

Educational Pearls

  • Subdural hematomas can happen in the elderly because of brain atrophy, and can manifest with neurological deficit.
  • Subdural hematomas are caused by rupture of the bridging veins of the brain. This can be caused by trauma, brain atrophy, or possibly by anticoagulant use. They are crescent-shaped on head CT.  
  • Epidural hematomas, in contrast, are caused by rupture of meningeal arteries secondary to trauma. They are usually lens-shaped on head CT.
  • Subdurals are difficult to pick up on head CT because they may be isodense to brain tissue.

References: Management of Recurrent Subdural Hematomas Desai, Virendra R. et al. Neurosurgery Clinics , Volume 28 , Issue 2 , 279 - 286

Dec 06, 2017
Podcast #277: Mucor
02:37

Author: Don Stader, M.D.

Educational Pearls

  • Mucor/Rhizopus fungal infections usually present in diabetic or immunocompromised patients as a black, necrotic lesion on the face.
  • The fungus invades the vasculature of the face, causing tissue ischemia and necrosis.
  • The infection is more common in the diabetic population because the fungus prefers more acidic and glucose-rich environments.
  • This is a surgical emergency since it is cured only with excision of the affected tissue

References: Vijayabala GS, Annigeri RG, Sudarshan R. Mucormycosis in a diabetic ketoacidosis patient. Asian Pacific Journal of Tropical Biomedicine. 2013;3(10):830-833. doi:10.1016/S2221-1691(13)60164-1.

Dec 04, 2017
Podcast #276: Angioedema
03:37

Author: John Winkler, M.D.

Educational Pearls

  • Angioedema is immediately life-threatening due to airway obstruction.
  • Mechanisms include allergic reaction (histamine-related) or bradykinin-related (ACE-inhibitor, C1 esterase inhibitor deficiency).
  • The bradykinin-related mechanism will not respond to the traditional meds used for anaphylaxis. Instead, use FFP to replace depleted factors.
  • If a patient displays signs of respiratory compromise, intubation is indicated. Anesthesia should be consulted as this will be a very difficult airway.

References: https://emcrit.org/pulmcrit/treatment-of-acei-induced-angioedema/

Dec 01, 2017
Podcast #275: Battery Ingestions
04:02

Author: Nick Hatch, M.D.

Educational Pearls

  • Unlike coin ingestions, button batteries can cause necrosis of the GI tract.
  • If lodged in the esophagus, removal within 2 hours is important, because they can cause problems such as strictures or esophago-aortic fistula.
  • If the battery is in the stomach or beyond, it may be ok to let it pass but give strict return precautions.
  • Small hearing aid batteries are not as dangerous, but still require close follow-up to ensure the battery passes.
  • Delayed effects (after passage of the battery) are possible.

References: https://www.poison.org/battery/guideline

Nov 29, 2017
Podcast #274: Pediatric Sedation
02:45

Author: Aaron Lessen, M.D.

Educational Pearls

  • A recent prospective observational study was performed to examine the safety of different sedation medications in the pediatric ED.
  • This study included 6000 children, and looked at the rate of serious adverse events following administration of different sedatives.
  • Overall, the safest drug to use was ketamine alone, with an adverse event rate of about 1%.
  • Propofol, BZDs, and opiates had increased rates of adverse events.

References: https://lifeinthefastlane.com/pediatric-procedural-sedation-with-ketamine/

Nov 27, 2017
Podcast #273: Bag Valve Masks
03:31

Author: Sam Killian, M.D.

Educational Pearls

  • Difficulty with bag valve mask (BVM) ventilation can be addressed using the MOANS mnemonic.
  • Mask seal, Obesity/obstruction,  Age, No teeth, Sleep apnea.
  • Often BVM difficulty can be addressed by an extra set of hands.

References: https://www.aliem.com/2012/10/mnemonics-for-difficult-airway/

Nov 17, 2017
Podcast #272: More on Temperature in Sepsis
02:18

Author: David Rosenberg, M.D.

Educational Pearls

  • A study of 20,000 subjects found that reducing fever in sepsis did not improve outcomes such as morbidity, mortality, or length of stay.
  • However, correcting fever may help for patient comfort.

References: Zhang Z, Chen L, Ni H. Antipyretic Therapy in Critically Ill Patients with Sepsis: An Interaction with Body Temperature. Azevedo LCP, ed. PLoS ONE. 2015;10(3):e0121919. doi:10.1371/journal.pone.0121919.

Nov 16, 2017
Podcast #271: Nexus Chest CT Scan Guidelines
03:20

Author: Chris Holmes, M.D.

Educational Pearls

  • The nexus chest CT scan rule is based on an 11,000 subject, multicenter study that looked for signs following a trauma that predicted significant findings on subsequent chest CT.
  • Findings that were associated with abnormal chest CT included: abnormal CXR, distracting injury, chest wall, sternal, thoracic spine or scapular tenderness. Furthermore, a mechanism of injury that includes rapid deceleration was also associated.
  • If a patient has none of the above findings, then there is only a small chance that there will be an abnormal chest CT.

References: https://www.mdcalc.com/nexus-chest-ct-decision-instrument-ct-imaging

Nov 13, 2017
Podcast #270: Wound Botulism
03:48

Author: Don Stader, M.D.

Educational Pearls

  • Wound botulism should be considered in patients with cutaneous lesions and  neuromuscular weakness.

  • The toxin produced by clostridium botulinum is the causative agent. It forms spores, so it is very resistant to killing by heat.

  • It presents with weakness, most often in the extraocular muscles.

  • Treatment includes wound care and respiratory support. Anti-toxin is rarely used as it is stored at the CDC and must be flown in.

References: Kalka-Moll WM, Aurbach U, Schaumann R, Schwarz R, Seifert H. Wound Botulism in Injection Drug Users. Emerging Infectious Diseases. 2007;13(6):942-943. doi:10.3201/eid1306.061336.

Nov 10, 2017
Podcast #269: Tattoo Ink Complications
04:29

Author: Michael Hunt, M.D.

Educational Pearls

  • Tattoo ink is applied below the skin, and because of this, they can lead to keloids, granulomas, tetanus, hepatitis B and C,  and skin infections.
  • Tattoo pigment has been found to contain substances like lead, cadmium, chromium, and arsenic; however, there are no long-term studies of the health effects of tattoos.
  • In one study 14% of inks had ingredients that were banned in cosmetics.
  • Nanoparticles of tattoo pigment can be found in the lymph nodes, and laser removal can precipitate their spread.
  • Those with tattoos could experience complications with MRI because of the metal content of the ink.

References: Khunger N, Molpariya A, Khunger A. Complications of Tattoos and Tattoo Removal: Stop and Think Before you ink. Journal of Cutaneous and Aesthetic Surgery. 2015;8(1):30-36. doi:10.4103/0974-2077.155072.

Nov 08, 2017
Podcast #268: Poiseuille’s Law
06:09

Author:  Dave Rosenberg, M.D.

Educational Pearls

  • Poiseuille’s Law addresses the flow of a fluid through a tube.
  • Many common ED presentations involve alterations in flow: asthma, MI, ischemic stroke, etc.
  • According to the law, flow increases with the 4th power of the radius. That is to say, doubling the radius of the tube will increase the flow by 16x.
  • Therefore, in situations that require re-opening of an anatomic tube (artery, airway), small changes in the size of the opening will result in dramatic effects.

References: https://www.openanesthesia.org/poiseuilles_law_iv_fluids/

Nov 06, 2017
Podcast #267: Causes of Very High Lactate
03:15

Author: Dylan Luyten, M.D.

Educational Pearls

  • Lactate is a byproduct of anaerobic metabolism, a sign of dying tissue. Dangerous causes of high lactates will not normalize with repeat labs.
  • Crush injuries, seizures, bowel necrosis,  end-stage liver disease, and metformin toxicity are common causes of highly elevated lactate.

References: https://lifeinthefastlane.com/ccc/lactic-acidosis/

Nov 03, 2017
Podcast #266: MI in Young Patients
01:52

Author: John Winkler, M.D.

Educational Pearls

  • Some risk factors for MI in the young are history of CAD, stimulant drug use, coronary spasm and diabetes.
  • In those with diffuse ST elevations on EKG, think pericarditis. Troponin will also be elevated.

References: Egred M, Viswanathan G, Davis GK Myocardial infarction in young adults Postgraduate Medical Journal 2005;81:741-745.

Nov 01, 2017
Podcast #265: The 2017 Flu Vaccine
04:51

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist - Emergency Medicine

Educational Pearls

  • CDC recommends using the inactivated, injectable flu vaccine in those 6 months and older. The live attenuated vaccine is not used because of low efficacy.
  • Pregnant women should be vaccinated, and can receive the vaccine at any stage of their pregnancy.
  • The vaccine is contraindicated ONLY in those with a history of a severe anaphylactic reaction to the injection in the past.
  • Antivirals (oseltamivir, zanamivir) are useful for Flu A and B. Their dosing needs to be adjusted for renal function, and it is contraindicated in those with ESRD who are not receiving dialysis. It should be used for prophylaxis in those with exposure and/or for the very young, very old, morbidly obese, nursing home residents, and those who are immunocompromised. They may be effective as long as 72 hours after symptom onset.

References: https://www.cdc.gov/flu/professionals/index.htm

Oct 30, 2017
Podcast #264: Witnessed Cardiac Arrest
02:51

Author: Aaron Lessen, M.D.

Educational Pearls

  • For patients with in-hospital cardiac arrest, intubation in the 1st 15 minutes of resuscitation was associated with worse outcomes (mortality, neurologic outcome). This is likely due to cessation of high-quality CPR and defibrillation during the intubation sequence.
  • In those with an in-hospital, shockable, cardiac arrest, administration of epinephrine before the 2nd defibrillatory shock was associated with worse outcome. This was likely due to the cessation of high-quality CPR.
  • For in-hospital cardiac arrest, resuscitation should focus on high-quality CPR.

References: Andersen LW, Granfeldt A, Callaway CW, Bradley SM, Soar J, Nolan JP, Kurth T, Donnino MW, for the American Heart Association’s Get With The Guidelines–Resuscitation Investigators. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA. 2017;317(5):494–506. doi:10.1001/jama.2016.20165

Oct 27, 2017
Podcast #263: Early Antibiotics in Sepsis
02:47

Educational Pearls

  • After the first hour, every 1 hour delay in antibiotics in a patient with septic shock patient is associated with a 4% increase in mortality.
  • In patients with high suspicion for septic shock (fever and hypotension), antibiotics should be initiated ASAP. Rocephin (ceftriaxone) should be used for those with community-acquired sepsis, zosyn for nosocomial or IV-associated sepsis.

References: https://lifeinthefastlane.com/ccc/antibiotic-timing/

Oct 25, 2017
Podcast #262: Pertussis
04:53

Author: Julian Orenstein, M.D.

Educational Pearls

  • Colorado has a high population of unvaccinated children, and is at increased risk for pertussis outbreaks.
  • The causative organism is Bordetella pertussis. It causes  causes respiratory epithelial necrosis leading to congestion of the bronchioles, leading to cough.
  • The cough is unique - it is usually a series of expiratory coughs followed by one deep inspiration
  • The clinical presentation is divided into 3 phases:
    • Catarrhal: cough and congestion with low-grade fever and coryza.
    • Whooping: characteristic cough.
    • Resolution: recovery with persistent cough.
  • Infants may not get this presentation, but may get apnea and nonspecific cough.  
  • Tongue depressor can be used to elicit cough for diagnosis.

References: Tozzi AE, Pastore Celentano L, Ciofi degli Atti ML, Salmaso S. Diagnosis and management of pertussis. CMAJ : Canadian Medical Association Journal. 2005;172(4):509-515. doi:10.1503/cmaj.1040766.

Oct 23, 2017
Deep Dive #7: Domestic Violence
37:29

Authors:

Katie Sprinkel, MD
Emergency Medicine Physician
SANE Medical Director, Medical Center of Aurora 
 
Amy Ferrin, Senior Deputy District Attorney
County Court Supervisor
Office of the District Attorney, 18th Judicial District

Amy Ferrin and Dr. Katie Sprinkel speak about the medical and legal aspects of domestic violence.
 
Oct 16, 2017
Podcast #261: Icatibant
02:11

Author: Aaron Lessen, M.D.

Educational Pearls

  • Icatibant was introduced to treat ACE-inhibitor induced angioendema.
  • This type of angioedema is refractory to epinephrine and antihistamines, and is likely mediated by elevated bradykinin.(which is inactivated by ATII and ACE).
  • Icatibant initially was shown to reduce facial swelling and airway obstruction in the setting of ACE-I angioedema, but later, better-powered studies showed that it had no benefit compared to standard treatment.

References: Sinert R et al. Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema. J Allergy Clin Immunol Pract 2017. PMID: 28552382

 

Oct 13, 2017
Podcast #260: Preoxygenation
02:46

Author: David Rosenberg, M.D.

Educational Pearls

  • Preoxygenation is done before rapid sequence intubation, and should be done even if SaO2 is at 100%.
  • Preoxygenation is done to fill the lungs with oxygen rather than ambient air, which is only 20% O2. While the patient is paralyzed, the O2-filled lungs will continue to oxygenate venous blood, buying you more time for intubation.  
  • BiPAP is an effective tool for pre-oxygenation.

References: https://lifeinthefastlane.com/ccc/preoxygenation/

Oct 11, 2017
Podcast #259: Transient Ischemic Attacks
07:21

 

Podcast #259: TIA

Author: Peter Bakes, M.D.

Educational Pearls

  • A TIA is defined as focal neurological deficit that resolves within 24 hours and has negative imaging. The etiology is a transient thrombus, embolus, or narrowing of a branch of a cerebral artery.
  • Screening tests are generally negative and low-yield. MRI and vascular imaging are usually done to look for reversible causes.
  • Patients presenting with TIA are usually admitted because of a higher risk for stroke. However, there are some patients that are low-risk and do not require admission. Risk can be assessed using the “ABCD” mnemonic: Age>60, BP (history of HTN), Clinical presentation (area of deficit), Diabetes/Duration of symptoms. See reference link for scoring sheet.
  • Patients with a low enough score may be eligible for outpatient follow-up.

References: http://www.stroke.org/sites/default/files/resources/tia-abcd2-tool.pdf?docID

Oct 09, 2017
Podcast #258: REBOA
03:55

Author: Dylan Luyten, M.D.

Educational Pearls

  • Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA).
  • Exsanguination is a major cause of mortality in trauma
  • One temporizing technique to buy time to definitive hemorrhage control is to occlude the aorta thereby shunting blood away from pelvis and lower extremities, increasing cardiac afterload to increase myocardial and brain perfusion.
  • Rather than perform a thoracotomy to cross clamp aorta, a REBOA catheter may be introduced into the aorta via the common femoral artery and a balloon inflated in the descending aorta to occlude it.
  • The indications for REBOA include PEA arrest of brief duration attributable to exsanguination for sub-diaphragmatic source in a young, healthy patient, or severe hypovolemic shock or those in an agonal state due to non-compressible hemorrhage not responding to volume and in whom obstructive cause of shock has been ruled out.
  • Contraindicated in prolonged arrest, suspected proximal aortic injury, advanced age/comorbidities.
  • Controversies and evidence:

     

    • High quality evidence is lacking - as it is for much of what we do and even consider standard of care in trauma. It has not been shown to improve survival, which is hard to demonstrate.

    • Role in remote settings vs trauma centers unclear.

    • Further refinements of indication for use are likely to occur with time and experience.

  • Summarize - REBOA is a promising relatively new technology that may have potential to improve outcomes in the sickest of trauma patients.

Oct 06, 2017
Podcast #257: Strangulation
04:41

Educational Pearls

  • Strangulation is common in cases of domestic violence and sexual assault, and it is associated with higher mortality
  • People who have been strangled have a higher rate of stroke due to vascular damage to carotid artery
  • Only 50% of people who die from strangulation show external signs of trauma
  • CTA should be done in all those who experience LOC or incontinence from strangulation  
  • 50-60sec of strangulation is all that is required to produce LOC

References: http://epmonthly.com/article/clinical-focus-strangulation-and-hanging-injuries/

Oct 04, 2017
Podcast #256: Fentanyl Ingestion
05:54

Authors:

Don Stader, M.D & Rachael Duncan, PharmD BCPS BCCCP

Educational Pearls

  • Fentanyl patches may be abused in many ways, including changing the patches more frequently, chewing them, extracting the fentanyl in a tea, and administering them rectally.
  • Fentanyl is very lipophilic and has a fast onset, but it has a very low bioavailability when given enterally, because it does not survive the stomach and 1st pass metabolism. It can be given IV, intranasal, through the buccal mucosa, or transdermal.
  • When patients present with fentanyl overdose due to ingestion of a patch, it is more important to find out how long the patient had the patch in their mouth, since that is the principal form of absorption.

References: http://www.medscape.org/viewarticle/518441_3

Oct 02, 2017
Deep Dive #6: Bacteriuria and the Elderly
29:04

Author: Heidi Wald, MD, MSPH 

Associate Professor of Medicine - University of Colorado School of Medicine, Physician Advisor - Colorado Hospital Association

Dr. Heidi Wald explains common misconceptions of UTI's in elderly patients and provides tips on how to properly identify them. 

References:

Trestioreanu , Adi Lador , May-Tal Sauerbrun-Cutler and Leonard Leibovici  Antibiotics for asymptomatic bacteriuria  Cochrane Collaborative Online Publication Date: April 2015.

Trautner BW, Bhimani RD, Amspoker AB, et al. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak 2013;13:48.

Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter Associated Asymptomatic Bacteriuria. JAMA Intern Med 2015. 

D'Agata ELoeb MB, and Mitchell.  Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc.2013 Jan;61(1):62-6. doi: 10.1111/jgs.12070.

Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965-77.

Sep 25, 2017
Podcast #255: Posterior Vitreous Detachment
01:50

Author: Erik Verzemnieks, M.D.

Educational Pearls

  • Posterior vitreous detachment is the tearing of the lining in the back of of the eye.
  • Patients often present with loss of vision and floaters.
  • Diagnosis can be made with US.
  • This is a benign diagnosis, but 10-15% can progress to retinal detachment , so follow up  with ophthalmology is recommended.

References: http://www.medscape.com/viewarticle/513226

Sep 22, 2017
Podcast #254: Myths About Antibiotic Course Length
04:45

Author: Chris Holmes, M.D.

Educational Pearls

  • There’s little/no data about the necessary length of an antibiotic course, nor has it proven that stopping a course of antibiotics early selects for the most resistant bugs.
  • There’s little incentive for drug companies to fund this type of study.
  • Pro-calcitonin levels have been used in some settings to distinguish if an infection has resolved or not, but this may not be feasible in an outpatient setting.

References: Llewelyn, Martin J et al. The antibiotic course has had its day. 2017. BMJ

Sep 20, 2017
Podcast #253: Total Eclipse of the Eye - Solar Retinopathy
03:54

Author: Nick Hatch, M.D.

Educational Pearls

  • Photic or solar retinitis occurs when you stare at the sun. The refractive power of the lens of the eye concentrates the light of the sun on the retina, stimulating the production of free radicals, damaging photoreceptors.
  • Solar retinitis may present hours-days after light exposure.
  • Patients will present with patchy loss of vision without pain, since the retina has no pain receptors.
  • In one study during an eclipse in the UK, of those who initially presented with vision loss due to solar retinitis, 92% recovered full vision.

References: Dobson R. UK hospitals assess eye damage after solar eclipse. BMJ : British Medical Journal. 1999;319(7208):469.

Sep 18, 2017
Podcast #252: Mandible Fractures
04:11

Author: Sam Killian, M.D.

Educational Pearls

  • The tongue blade test is done for mandible fractures, which make up 40-60% of facial fractures.
  • The test is done by having the patient bite down on a tongue depressor on one side of the mouth. The provider then tries to snap the tongue depressor. This is repeated on the other side of the mouth. The test is positive if the patient complains of pain before the depressor can be broken on either side.  
  • It has been compared to CT and X-ray and has a similar sensitivity and specificity (95% and 65%, respectively).

References: J. Neiner, et al. Tongue Blade Bite Test Predicts Mandible Fractures. Craniomaxillofac Trauma Reconstr. 2016

 

Sep 15, 2017
Podcast #251: Cyanide Poisoning
04:36

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist – Emergency Medicine

Educational Pearls

  • Cyanide poisoning is suspected in patients who present with lactic acidosis after being trapped around burning household objects. It affects our ability to metabolize and can quickly lead to CV collapse and death.  
  • Because cyanide blood levels are not quickly available, the diagnosis is made by history and lactic acidosis on ABG.
  • The cyanokit is the key treatment. It contains hydroxocobalamin, which binds to cyanide so it can be excreted.
  • One side effect to be aware of is that the cyanokit will turn everything red, including mucous membranes, saliva, urine, and skin. This will interfere with some lab values, so make sure to get labs before administration.

References: Mégarbane B, et al. Antidotal treatment of cyanide poisoning. J Chin Med Assoc. 2003

Sep 13, 2017
Podcast #250: Desmopressin
03:21

Author: Rachael Duncan, PharmD BCPS BCCCP

Educational Pearls

  • Desmopressin is an ADH mimetic and helps retain water, release von Willibrand Factor (in high doses), and treat diabetes insipidus (in low doses).
  • It can also be used in renal colic, because it may reduce muscle spasm in the ureters.
  • The dosing for renal colic is very small (40 micrograms).

References: http://reference.medscape.com/drug/ddavp-stimate-noctiva-desmopressin-342819

Sep 11, 2017
Podcast #249: Detecting Pulses
03:07

Author:  Jared Scott, M.D.

Educational Pearls

  • Overall, medical providers are bad at detecting pulses.
  • However, only 2% of patients do not have a detectable DP pulse.
  • In one study, for patients with limb claudication, there was only about 50% agreement on the presence of a DP pulse.

References: Brearley et al. Peripheral pulse palpation: an unreliable physical sign. Annals of the Royal College of Surgeons of England. 1992

Sep 10, 2017
Podcast #248: Family Presence During Resuscitation
03:32

Author: Aaron Lessen, M.D.

Educational Pearls

  • Traditionally the family is removed from the room during procedures and codes, but recent research shows that family presence may be beneficial.
  • 50% patients want family present during a code.
  • Family-related outcomes were improved with presence.
  • There was no change in medical outcomes, and no increased incidence of medicolegal issues.

References: Jabre et al. Family Presence during Cardiopulmonary Resuscitation. NEJM. 2013.

Sep 08, 2017
Podcast #249: D-Dimer
03:45

Author: Michael Hunt, M.D.

Educational Pearls

  • In the recent YEARS study, investigators checked every patient with suspicion for PE with a D-dimer, using a modified Wells score for risk stratification. The goal of the study was to show that CT scan usage could safely reduced using this screening method.
  • The Wells Criteria measures they used to stratify risk were: PE mostly likely dx, hemoptysis, and evidence of DVT. If the d-dimer was 1, but the patient had none of the Wells criteria, the patient did not get a CT. If the patient had any of the criteria, but the d-dimer was only 0.5, the patient did not get a CT scan.
  • The investigators reduced  CT usage by 14% using the new criteria, with no significant increase in morbidity and mortality.

References: van der Hulle et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. The Lancet. 2017

Sep 06, 2017
Podcast #248: Patent Foramen Ovale
03:40

Author: Jared Scott, M.D.

Educational Pearls

  • The foramen ovale (FO) connects the left and right atria to allow oxygenated blood to bypass the developing lungs, it usually closes at birth but for some it remains patent (PFO).
  • A PFO allows clots to cross from the venous to arterial circulation, increasing the likelihood of stroke.
  • PFO is present in 25% of general population, present in 50% of those with stroke of unknown cause, and very common those with stroke under 50 years old.
  • Treat with anticoagulation or surgical correction.

References: http://www.heart.org/HEARTORG/Conditions/More/CardiovascularConditionsofChildhood/Patent-Foramen-Ovale-PFO_UCM_469590_Article.jsp#.WarsZZN95E4

Sep 04, 2017
Podcast #247: Are You Listening? - 3 Ear Emergencies You Can't Miss!
06:05

Author: Don Stader, M.D.

Educational Pearls

  • Ear pain is a common complaint in adults and kids.
  • A red, hot, painful ear with involvement of the pinna could indicate perichondritis - an infection of the cartilage that is usually caused by pseudomonas.
  • A painful, swollen ear with involvement of the mastoid process could be mastoiditis, which needs to be treated with IV antibiotics to avoid cerebellar abscess.
  • Ear pain with significant drainage and a cranial nerve deficit points to malignant otitis externa, which needs to be treated with IV antibiotics.

References: John W. Ely,  Marlan R. Hansen,  Elizabeth C. Clark. Diagnosis Of Ear Pain. 2008. American Family Physician.

Sep 02, 2017
Podcast #246: Fever in Sepsis
02:48

Author: Nick Hatch, M.D.

Educational Pearls

  • A recent observational cohort study found that the biggest predictor for sepsis survival was fever. Those with higher fevers had better outcomes.
  • Some possible explanations for this finding are that high fevers indicate good immune response or that high fever cued providers to treat sepsis more aggressively.

References: Paul J Young,  Rinaldo Bellomo. Fever in Sepsis: is it cool to be hot?. 2014. Critical Care

Aug 31, 2017
Podcast #245: Hypoglycemia
04:00

Author: Dylan Luyten, M.D.

Educational Pearls

  • Hypoglycemia is very common in type 2 diabetics, and is often caused by insulin overdose or missed meals. Knowing the peak time of action for common diabetes medications can help inform treatment and disposition.
  • Regular insulin’s action peaks around 60 minutes. By the time most of these patients present to the ED, the drug has had most of its effect.
  • Lantis’ action does not peak, and will continue to exert its effect for 12 or more hours.
  • Levamir has a peak around 6-8 hours.
  • Metformin sensitizes tissues to insulin, so it cannot cause hypoglycemia alone.
  • Glipizides have half-lives over 12 hours and work by increasing insulin release by the pancreas. Hypoglycemia in a patient taking a glipizide usually indicates there is another medical issue interfering with clearance

References: http://emedicine.medscape.com/article/122122-workup

Aug 29, 2017
Podcast #244: Clavicle Fracture Review
02:49

Author: Nick Hatch, M.D.

Educational Pearls

  • The force required to break a clavicle is significant, so clavicle fracture may be associated with other injury (pneumothorax, vascular injury).
  • Most fractures occur in the middle 1/3 of the clavicle.
  • Traditionally, clavicle fractures have been managed without surgery. However, recent studies have shown that surgery may be beneficial in a larger population than previously thought.

References: http://emedicine.medscape.com/article/398799-overview

Aug 27, 2017
Podcast #243: Sphenopalatine Nerve Block
04:53

Author: Don Stader, M.D.

Educational Pearls

  • Cluster headaches are usually intense, unilateral,  and involve the periorbital area.
  • CN V (Trigeminal) provides sensory and autonomic innervation the face and eyes, which play roles in headache pathology.
  • Cluster headaches can be treated with high flow oxygen, but a new treatment involves blocking the sphenopalatine ganglion (SPG) with lidocaine. Because sensory and autonomic branches of the trigeminal traverse the SPG, lidocaine will effectively treat a cluster headache.
  • To block the ganglion, intranasal lidocaine may be used, or a Q-tip soaked in 4% lidocaine can be applied to the most posterior aspect of the pharynx for 10-15 minutes.

References: https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/

Aug 25, 2017
Podcast #242: Pott's Puffy Tumor
03:05

Author: Suzanne Chilton, M.D.

Educational Pearls

  • Pott’s puffy tumor is a subperiosteal abscess of the frontal bone that arises from hematologic spread or direct infection via the frontal sinuses. The primary symptom is facial swelling.
  • It is much more common in children and adolescents.
  • Treatment involves removal of the frontal bone, reconstructive surgery, and 6-8 weeks of IV antibiotics.

References: Grewal HS, Dangaych NS, Esposito A. A tumor that is not a tumor but it sure can kill! The American Journal of Case Reports. 2012;13:133-136. doi:10.12659/AJCR.883236.

Aug 23, 2017
Podcast #241: GERD vs. MI
03:35

Author: Dave Rosenberg, M.D.

Educational Pearls

  • MI and GERD can present similarly. For example, 47% with angina report increased belching with an anginal attack, and 20% of people with an MI describe symptoms  of indigestion that are relieved by antacids.
  • Overall, GERD is more common in those with CAD, so don’t be “reassured” by GERD symptoms in the setting of chest pain.

References: http://www.mdedge.com/ecardiologynews/article/82215/cad-atherosclerosis/gerd-may-boost-risk-mi

Aug 21, 2017
Podcast #240: Honey and Burns
02:30

 

Podcast #240: Honey and Burns

Author: Nick Hatch, M.D.

Educational Pearls

  • Honey can be used to treat burns because it has antibacterial properties. In one study, honey outperformed silver sulfadiazine for burn treatment, but more research is needed in this area.
  • In practice, honey is likely more useful outside the ER than inside the ER.

References: Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey Dressing Versus Silver Sulfadiazene Dressing for Wound Healing in Burn Patients: A Retrospective Study. Journal of Cutaneous and Aesthetic Surgery. 2011;4(3):183-187. doi:10.4103/0974-2077.91249.

Aug 19, 2017
Podcast #239: Tetanus in the ED
03:09

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist - Emergency Medicine

Educational Pearls

  • Tetanus Ig is indicated in those who have no or unknown tetanus vaccination history who present with contaminated cuts that or dirty puncture wounds
  • The tetanus vaccine is a 5 shot series (DTAP) for children, TDAP is used for adults
  • There is no harm is receiving the TDAP more than once if vaccination history is unknown

References: https://www.cdc.gov/features/tetanus/index.html

Aug 17, 2017
Podcast #238: Ultrasound in Cardiac Arrest
01:57

Author: Aaron Lessen M.D.

Educational Pearls

  • Ultrasound  is helpful in the setting of cardiac arrest for finding a cause like cardiac tamponade or PE, but also for predicting outcomes for non-shockable rhythms.
  • One study showed that in those that presented with asystole or PEA and cardiac activity on US had a 4% survival rate, while those without cardiac activity had almost no chance.

References:  Philip Salen, Larry Melniker, Carolyn Chooljian, John S. Rose, Janet Alteveer, James Reed, Michael Heller, Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients?, The American Journal of Emergency Medicine, Volume 23, Issue 4, 2005, Pages 459-462, ISSN 0735-6757, http://dx.doi.org/10.1016/j.ajem.2004.11.007.

Aug 15, 2017
Deep Dive #5: The Evolution of Sepsis Treatment
22:12

Author: Susan Brion, M.D.

 

Dr. Brion enlightens us on the ever-evolving standard of sepsis management.

Aug 11, 2017
Podcast #237: Phimosis vs. Paraphimosis
04:19

Author: Sam Killian, M.D.

Educational Pearls

  • Phimosis refers to the inability to retract the distal foreskin over the glans penis in uncircumcised males. Paraphimosis is the entrapment of the foreskin proximal to the glans penis in these patients.
  • Phimosis is rarely a medical emergency, but requires follow up with urology. Paraphimosis, on the other hand, can cause venous and lymphatic insufficiency, leading to infarction, necrosis and autoamputation. Therefore, paraphimosis requires emergent treatment with manual reduction of the foreskin or surgery.

References:

Aaron Vunda, M.D., Laurence E. Lacroix, M.D., Franck Schneider, Sergio Manzano, M.D., and Alain Gervaix, M.D. Reduction of Paraphimosis in Boys. N Engl J Med 2013; 368:e16

Aug 09, 2017
Podcast #236: Peripheral IJ Access
04:07

Author: Nick Hatch, M.D.

Educational Pearls

  • When peripheral or central IV access is difficult, sometimes providers will try to use a peripheral IV setup at an IJ site using US guidance.
  • Case studies have shown that this method is often successful, with the most common complication being the loss of access.

References: Ash AJ, Raio C. Seldinger Technique for Placement of “Peripheral” Internal Jugular Line: Novel Approach for Emergent Vascular Access. Western Journal of Emergency Medicine. 2016;17(1):81-83. doi:10.5811/westjem.2015.11.28726.

Aug 07, 2017
Podcast #235: ER Discharge and Mortality
06:55

Author: Pete Bakes, M.D.

Educational Pearls

  • One of the roles of the ER provider is to discharge patients only after life-threatening conditions have been ruled out. However, some patients that are discharged from the ED die within days of their discharge. One recent study sought to investigate the factors and diagnoses associated with death within 7 days of discharge.
  • This study was a retrospective study in 10 million medicare recipients that presented to the ER over 10 years. They excluded palliative, hospice and SNF patients.
  • 0.12% of these patients died within 7 days of ER discharge. Signs and symptoms such as altered mental status, general malaise and fatigue, and nonspecific dyspnea had relative risks of 3-5 for death following discharge.
  • Think carefully before discharge in patients with the signs/symptoms above.  

References: Obermeyer Ziad, Cohn Brent, Wilson Michael, JenaAnupam B, Cutler David M. Early death after discharge from emergency departments: analysis of national US insurance claims data BMJ 2017;356 :j239

Aug 05, 2017
Podcast #234: CIN AEM Study
03:28

Author: Dylan Luyten, M.D.

Educational Pearls

  • Around 30% of patients in the ER receive CT imaging, and the sensitivity of CT imaging may be improved with IV contrast. However, contrast is often withheld for fear of contrast-induced nephropathy.
  • A recent, single-center, retrospective cohort study compared the rates of nephropathy between contrast CT, non-contrast CT, and no CT control patients, and found no differences.
  • This study confirms what many have believed to be true - that the dangers of modern contrast may be overstated. However, the results should be interpreted with caution, as this was a retrospective, single-center study.

References: Hinson, Jeremiah S. et al.. Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Annals of Emergency Medicine , Volume 69 , Issue 5 , 577 - 586.e4




Aug 03, 2017
Podcast #233: Carfentanil
04:30

Author: Don Stader, M.D. and Rachael Duncan, PharmD BCPS BCCCP

Educational Pearls

  • Carfentanil is an opioid elephant tranquilizer that can be used recreationally.  It is 1000 times stronger than fentanyl, and looks like a white powder.
  • Healthcare workers must be cautious when carfentanil overdose is suspected, as the drug can be absorbed through caregivers’ skin if it is present on the patient’s clothes.
  • Overdose may require large amounts of naloxone, and a drip may be started at a rate equivalent to the bolus dose that the patient responded to. For example, if the patient responded to a 10mg bolus dose of naloxone, he would then be started on a 10mg/hr naloxone drip.

References: https://www.dea.gov/divisions/hq/2016/hq092216.shtml

Aug 01, 2017
Podcast #232: HAPE
06:07

Author: Gretchen Hinson, M.D.

Educational Pearls

  • High-Altitude Pulmonary Edema (HAPE) is caused when hypoxemia due to low ambient pO2 leads to breakdown and constriction of the pulmonary vasculature leading to edema.
  • HAPE is very rare under 8000 ft, but common over 10000 ft (6%). Over 18,000 ft the incidence is very high (12-15%).
  • Symptoms include dyspnea, cough, weakness and chest tightness.
  • Signs include hypoxemia, crackles, wheezing, central cyanosis, tachypnea and tachycardia.
  • Drugs that reduce pulmonary resistance have been shown to help, but increased oxygenation and descent are the best treatments.

References: http://emedicine.medscape.com/article/300716-overview

Jul 30, 2017
Podcast #231: Esophageal Tearing
04:42

Author: Jared Scott, M.D.

Educational Pearls

  • Boerhaave syndrome (aka effort rupture of the esophagus) accounts for 10% of esophageal ruptures and is usually caused by strain during vomiting episodes. It can also be caused by childbirth, seizure, or prolonged coughing or laughing.  
  • Food and water swallowed after the tear end up in the mediastinum, eventually causing infection. Therefore, Boerhaave syndrome is a surgical emergency.
  • Best diagnostic techniques are CT or endoscopy.
  • Mallory-Weiss syndrome may present similarly, however it is less serious since it involves only a small tear through the mucosa at the gastroesophageal junction. This can be managed on an outpatient basis with PPI’s.

References: https://radiopaedia.org/articles/boerhaave-syndrome

Jul 28, 2017
Podcast #230: Concussive Treatment
02:26

Author: Aaron Lessen, M.D.

Educational Pearls

  • 2 studies this past year looked at pediatric and adolescent patients following a concussion. They found people who returned to activity sooner did better than those who went on “brain rest”.  
  • While patients should still follow up with their PCP following a concussion, it is ok for patients to return to physical activity as tolerated.

References: Grool AM, Aglipay M, Momoli F, Meehan WP, Freedman SB, Yeates KO, Gravel J, Gagnon I, Boutis K, Meeuwisse W, Barrowman N, Ledoux A, Osmond MH, Zemek R, for the Pediatric Emergency Research Canada (PERC) Concussion Team. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504-2514. doi:10.1001/jama.2016.17396

Jul 26, 2017
Podcast #229: Andrew Jackson
05:30

Author: Sam Killian, M.D.

Educational Pearls

  • Andrew Jackson was the 7th president of the USA. He served 2 terms from 1829-1837.
  • He had had many medical issues during his presidency. He was said to be chronically underweight with rotting teeth. Furthermore, he had chronic infections and lead poisoning from bullets lodged in his arm and chest.
  • He suffered from smallpox that he contracted while in a British prison during the Revolutionary War.
  • He died from “dropsy” (CHF).

References: http://www.doctorzebra.com/prez/g07.htm

Jul 24, 2017
Podcast #228: BB Guns
04:28

Author: Jared Scott, M.D.

Educational Pearls

  • BB gun eye injuries are most common in August and September. They most often happen to males aged 16-17 year old. Around 10% of the BB eye injuries lead to eye loss.
  • Accidental firearm injury is common in children and is a common cause of mortality. One-third of homes with children have a firearm.
  • Most accidental pediatric gun injuries happen to young, male children with guns owned by family members. It is important to educate gun owners about proper gun storage.

References: Childhood Firearm Injuries in the United States Katherine A. Fowler, Linda L. Dahlberg, Tadesse Haileyesus, Carmen Gutierrez, Sarah Bacon. Pediatrics Jun 2017, e20163486; DOI: 10.1542/peds.2016-3486

Jul 22, 2017
Podcast #227: CPR-Induced Consciousness
03:51

Author: Nick Hatch, M.D.

Educational Pearls

  • CPR-induced consciousness is a phenomenon that occurs when someone who was previously unconscious and is undergoing CPR regains consciousness and makes purposeful movements.
  • Studies have shown that this phenomenon is increasing, likely because of increased quality of CPR.
  • Many people use a sedative such as ketamine  to keep patients unconscious to reduce the psychologic trauma of CPR.
  • 39% of people who survive CPR with good neurologic details remember the process of CPR  .

References:

Joshua Pound, P. Richard Verbeek, and Sheldon Cheske. CPR Induced Consciousness During Out-of-Hospital Cardiac Arrest: A Case Report on an Emerging Phenomenon. 2017. Prehospital Emergency Care Vol. 21.

 

Jul 20, 2017
Podcast #226: Biphasic Anaphylaxis
03:21

Author: Sam Killian, M.D.

Educational Pearls

  • Anaphylaxis is common in the ED. These patients are treated and then usually watched for 4-6 hours.
  • Biphasic happens in patients that have a complete resolution of their anaphylaxis  for at least an hour, but then have a recurrence that requires pharmacologic  intervention. Most of the time this happens 3-6 hours later, but can happen more than 10 hours later.
  • More commonly happens in patients that have a delayed presentation,  a wide pulse pressure, need multiple doses of epi, require the use of  a beta agonist, or are ages 6-9 years old.
  • Educate patients about the possibility of Biphasic anaphylaxis before discharge. 

References: http://www.medscape.org/viewarticle/583328_7

 

Jul 18, 2017
Podcast #225: Rhogam
04:22

Author: Dylan Luyten, M.D.

Educational Pearls

  • Rhogam is commonly used when an Rh negative woman has an Rh positive fetus. It is commonly used in the ER in the setting of a miscarriage.
  • Rh(+) fetal blood can enter the Rh(-) maternal circulation, sensitizing the woman to the Rh antigen. During a subsequent pregnancy, if the fetus is Rh(+), the woman may mount an immune response to the fetus, lead to fetal demise. Rhogam is used to block this process.
  • Use of Rhogam has reduced this complication from 16% of Rh(+) pregnancies in the 1960’s to less than 1% today.
  • Under 10 weeks, the amount of maternal-fetal blood exchange is very small, so the use of Rhogam in a 1st trimester miscarriage is unnecessary. It should be used in patients with a miscarriage after 12 weeks, or women undergoing a surgical D&C.
  • Rhogam is expensive and in limited supply, so it is important to only use it when necessary.

References: Hannafin, Blaine et al. Do Rh-negative women with first trimester spontaneous abortions need Rh immune globulin? 2006.  The American Journal of Emergency Medicine, Volume 24 , Issue 4 , 487 - 489

Jul 16, 2017
Deep Dive #4: Pediatric Type I DKA
47:18

Author: Justin Harper

Justin Harper, a paramedic married to a pediatric nurse, discovered his own son had type I diabetes 2 years ago. Despite their medical experience, this diagnosis came as surprise to Justin and his wife. This is the compelling story about how their son was diagnosed with type I diabetes and how this has impacted their lives. 

Jul 14, 2017
Brewcast Part VIII: Cannabis in Colorado
17:59

Author: Dr. Larry Wolk, Executive Director and Chief Medical Officer for the Colorado Department of Public Health and Environment.

Topic: Dr. Larry Wolk educates us on how cannabis has affected Colorado since medical and recreational legalization.

Jul 09, 2017
Brewcast Part VII: A Patient's Perspective on Medical Marijuana
20:26

Authors: Don Stader, M.D. & Lauren Gibbs

Topic: Lauren breaks the stoner stereotype and explains how marijuana has positively impacted her life.

Jul 08, 2017
Brewcast Part VI: Synthetic Marijuana
12:09

Author: Erik Verzemnieks, M.D.

Topic: Erik speaks about how slightly altering the chemical composition of marijuana can create a drug with drastic effects on the human body.

WARNING: Explicit Language

Jul 07, 2017
Brewcast Part V: Researching Cannabis
17:31

Author: Sophie Yorkwilliams

-B.A. (Psychology)

-Dual Ph.D. Candidate, Clinical Psychology and Neuroscience. Expected graduation: 2020

Topic: Studying cannabis comes with its own set of challenges. Find out how Sophie and her team have overcome obstacles to get accurate data on marijuana.

Jul 06, 2017
Brewcast Part IV: A Physician's Perspective on Medical Marijuana
23:49

Authors: Don Stader, M.D. & Peter Pryor, M.D.

Topic: What caused Dr. Pryor to leave emergency medicine and enter the realm of medical marijuana?

Jul 05, 2017
Brewcast Part III: Cannabinoid Hyperemesis Syndrome
14:58

Author: Rachael Duncan, PharmD BCPS BCCCP

Topic: Rachel explains the science behind one of the most common maladies thought to be induced by chronic cannabis use.

Jul 04, 2017
Brewcast Part II: Pharmacology of Cannabis
18:57

Author: Brett Marlin, M.D.

Topics: Brett explains the biochemical and physiological properties of cannabis.

Jul 03, 2017
Brewcast Part I: The History of Cannabis in Medicine
20:51

Author: Don Stader, M.D

Topic: Don kicks things off with an overview of the history of marijuana and how it has made its way into medicine.

Jul 02, 2017
Podcast #224: Troponin
04:09

Author: Sam Killian, M.D.

Educational Pearls

  • Not every troponin elevation is an MI.
  • Trop elevates in about an hour in ACS and stays elevated for days.
  • Non-MI conditions that cause elevated troponin: Critical illness (sepsis), increased cardiac demand, right heart strain, LV dysfunction, hypotension, pressor use, acute PE, SAH, chronic renal failure, CHF, aortic dissection, and peri/myocarditis.
  • Elevated troponin in settings other than MI is correlated with increased mortality.

References: Korff S, Katus HA, Giannitsis E. Differential diagnosis of elevated troponins. Heart. 2006;92(7):987-993. doi:10.1136/hrt.2005.071282.

Jul 01, 2017
Podcast #223: Acyclovir Toxicity
02:41

Author: Nick Hatch, M.D.

Educational Pearls

  • Acyclovir toxicity can uncommonly cause altered mental status, low blood glucose, hallucinations and myoclonic jerks.
  • Toxicity often occurs in the setting of renal insufficiency, as it is cleared by the kidneys.
  • Acyclovir is often used to treat shingles, which can also cause similar symptoms as acyclovir toxicity due to encephalitis - rule this out in the setting of a concomitant shingles infection.

References: http://www.rxlist.com/zovirax-drug.htm

Jun 29, 2017
Podcast #222: Wells Criteria for PE
04:41

 

Author: Michael Hunt, M.D.

Educational Pearls

  • Wells Criteria was initially designed to screen patients for further workup for PE.  
  • Aspects of the Wells Criteria include: signs and symptoms of DVT (3 points), PE most likely dia (3 points), HR > 100 (1.5 points), immobility for > 3 days or surgery in last 4 weeks (1.5 points), documented history of PE (1.5), hemoptysis (1), treatment for cancer in last 6 mo (1).
  • ACEP uses a score of less than or equal to 4 to define “low risk.” Greater than 4 is “high risk”.
  • Use Wells to guide clinical decisions about PE workup.

References: http://www.ebmedicine.net/media_library/files/1212%20Pulmonary%20Embolism

Jun 27, 2017
Podcast #221: Walking Corpse Syndrome
01:55

Podcast #221: Walking Corpse Syndrome

Author: Erik Verzemnieks, M.D.

Educational Pearls

  • Walking Corpse Syndrome (aka Cotard Delusion) is a very rare psychiatric disorder that leads to the belief that one is a “walking corpse”.
  • Often co-presents with depression, schizophrenia, and starvation.
  • Responds to ECT.

References: https://en.wikipedia.org/wiki/Cotard_delusion

Jun 25, 2017
Podcast #220: A-Fib Cardioversion
02:35

Author: Aaron Lessen, M.D.

Educational Pearls

  • Atrial fibrillation is common.
  • One of the best treatments for a fib is cardioversion back into sinus rhythm.
  • Cardioversion may increase stroke risk if A-Fib duration is greater than 48 hours, but some new data suggests that this risk may happen as soon as 12 hours.
  • However, newer studies show that cardioversion is generally safe as a treatment for A-Fib.

References: Aatish Garg, Monica Khunger, Sinziana Seicean, Mina K. Chung, Patrick J.Tchou Incidence of Thromboembolic Complications Within 30 Days of Electrical Cardioversion Performed Within 48 Hours of Atrial Fibrillation Onset. JACC: Clinical Electrophysiology Aug 2016, 2 (4) 487-494; DOI: 10.1016/j.jacep.2016.01.018

Jun 23, 2017
Podcast #219: History of Sepsis
06:20

 

Author: Chris Holmes, M.D.

Educational Pearls

  • “Sepo’ is a term from Homer (author of The Iliad and The Odyssey), and means “I rot”.
  • Hippocrates in 400 BC identified sepsis as a “dangerous decay within the body”.
  • Galen in 200 AD believed pus was “laudable”.
  • The Greeks and Romans used the term “myasma” to describe the smell of swamp and rotting flesh.
  • Dr. Emmanuel Rivers in Detroit did one of the the first big studies about sepsis and was an advocate for goal-directed therapy.
  • Now, Vitamin C cocktails are in use, but new sepsis treatments should be investigated carefully before implementation.

References: Funk, Duane J. et al. Sepsis and Septic Shock: A History. Critical Care Clinics , Volume 25 , Issue 1 , 83 - 101

Jun 21, 2017
Podcast #218: Estimating Pediatric Weight
02:45

Author: Aaron Lessen, M.D.

Educational Pearls

  • Asking parents and Broselow Tape are common options for estimating pediatric weight.
  • Equipment sizes should not be adjusted for under/overweight kids based on Broselow Tape estimates.
  • The finger counting method (see reference) is just as accurate as Broselow Tape method, according to one study.

References: http://handtevy.com/images/Casestudies/Americanjournalofemergencymedicine.pdf

Jun 19, 2017
Podcast #217: Designer Drugs
03:05

Author: John Winkler, M.D.

Educational Pearls:

  • Designer, or “synthetic” drugs include bath salts, synthetic THC, and many others.
  • Many of these drugs are originally manufactured in China and are shipped globally.
  • Treatment usually involves airway control and sedation - ketamine may be useful.
  • Traditional tox screens do not test for these drugs.

References: https://www.drugabuse.gov/related-topics/trends-statistics/national-drug-early-warning-system-ndews

Jun 17, 2017
Podcast #216: Roller Coasters and Kidney Stones
01:58

Author: Aaron Lessen, M.D. 

Educational Pearls:

  • Anecdotal evidence suggests that roller coasters may help with kidney stones.
  • A recent study used a model of a kidney and ureter with different sized stones and put it on Thunder Mountain roller coaster in Disney World.
  • There was “dramatic passage” of the kidney stones at the rear of the roller coaster.

References: Marc A. Mitchell, DO; David D. Wartinger, DO, JD. Validation of a Functional Pyelocalyceal Renal Model for the Evaluation of Renal Calculi Passage While Riding a Roller Coaster. The Journal of the American Osteopathic Association, October 2016, Vol. 116, 647-652. doi:10.7556/jaoa.2016.128. http://jaoa.org/article.aspx?articleid=2557373

Jun 13, 2017
Opioid MIniseries Part IV: Harm Reduction
48:36

PRACTICE RECOMMENDATIONS

1. Patients who abuse opioids should be managed without judgement; addiction is a medical condition and not a moral failing. Caregivers should endeavor to meet patients “where they are,” infusing empathy and understanding into the patient/medical provider relationship.

2. Every emergency clinician should be well-versed in the safe injection of heroin and other intravenous (IV) drugs, and understand the practical steps for minimizing the dangers of overdose, infection, and other complications. When treating patients with complications of IV drug use, injection habits should be discussed and instruction should be given about safe practices.

3. Emergency department patients who inject drugs should be referred to local syringe access programs, where they can obtain sterile injection materials and support services such as counseling, HIV/hepatitis testing, and referrals.

4. Emergency departments should provide naloxone to high-risk patients at discharge. If the drug is unavailable at the time of release, patients should receive a prescription and be informed about the over-the-counter availability of the drug in most Colorado pharmacies.

5. Emergency clinicians should be familiar with Colorado’s regulations pertaining to naloxone. State laws eliminate liability risk for prescribing the drug, encourage good samaritan reporting of overdose, and make naloxone legal and readily available over the counter in most pharmacies.

6. Emergency department patients who receive prescriptions for opioids should be educated on their risks, safe storage methods, and the proper disposal of leftover medications.

POLICY RECOMMENDATIONS

1. Harm reduction agencies and community programs that provide resources for people who inject drugs (PWID) should be made readily available.

2. When local programs are unavailable for PWID, emergency departments should establish their own programs to provide services such as safe syringe exchanges.

Jun 08, 2017
Opioid Miniseries Part III: Alternative to Opioids
49:39

PRACTICE RECOMMENDATIONS

1. All emergency departments should implement ALTO programs and provide opioid-free pain treatment pathways for

the following conditions:

a. Acute on chronic opioid-tolerant radicular lower back pain

b. Opioid-naive musculoskeletal pain

c. Migraine or recurrent primary headache

d. Extremity fracture or joint dislocation

e. Gastroparesis-associated or chronic functional abdominal pain

f. Renal colic

2. Emergency departments should integrate ALTO into their computerized physician order entry systems to facilitate a seamless adoption by clinicians.

3. Low-dose, subdissociative ketamine (0.1-0.3 mg/kg) is an effective analgesic that can be opioid-sparing for many acute pain syndromes. Institutional guidelines and policies should be in place to enable clinicians and nurses who administer this agent for pain.

4. For musculoskeletal pain, consider a multimodal treatment approach using acetaminophen, NSAIDs, steroids, topical medications, trigger-point injections, and (for severe pain) ketamine.

5. For headache and migraine, consider a multimodal treatment approach that includes the administration of antiemetic agents, NSAIDs, steroids, valproic acid, magnesium, and triptans. Strongly consider cervical trigger-point injection.

6. For pain with a neuropathic component, consider gabapentin.

7. For pain with a tension component, consider a muscle relaxant.

8. For pain caused by renal colic, consider an NSAID, lidocaine infusion, and desmopressin nasal spray.

9. For chronic abdominal pain, consider low doses of haloperidol, diphenhydramine, and lidocaine infusion.

10. For extremity fracture or joint dislocation, consider the immediate use of nitrous oxide and low-dose ketamine while setting up for ultrasound-guided regional anesthesia.

11. For arthritic or tendinitis pain, consider an intra-articular steroid/anesthetic injection.

POLICY RECOMMENDATIONS

1. Hospitals should update institutional guidelines and put policies in place that enable clinicians to order and nurses to administer dose-dependent ketamine and IV lidocaine in non-ICU areas.

2. Emergency departments are encouraged to assemble an interdisciplinary pain management team that includes clinicians, nurses, pharmacists, physical therapists, social workers, and case managers.

3. Reimbursement should be available for any service directly correlated to pain management, the reduction of opioid use, and treatment of drug-addicted patients.

Jun 08, 2017
Opioid Miniseries Part II: Limiting Opioids in the Emergency Department
01:08:49

RACTICE RECOMMENDATIONS

1. Opioids are inherently dangerous, highly addictive drugs with significant abuse potential, numerous side effects, lethality in overdose, rapid development of tolerance, and debilitating withdrawal symptoms. They should be avoided whenever possible and, in most cases, initiated only after other modalities of pain control have been trialed.

2. Prior to prescribing an opioid, physicians should perform a rapid risk assessment to screen for abuse potential and medical comorbidities. Alternative methods of pain control should be sought for patients at increased risk for abuse, addiction, or adverse reactions.

3. Emergency physicians should frequently consult Colorado’s prescription drug monitoring program (PDMP) to assess a patient’s history of prescription drug abuse, misuse, or diversion.

4. Emergency physician groups should strongly consider tracking, collecting, and sharing individual opioid prescribing patterns with their clinicians to decrease protocol variabilities.

5. Strongly consider removing prepopulated doses of opioids from order sets in computerized provider order entry (CPOE) systems.

6. Opioid alternatives and nonpharmacological therapies should be used to manage patients with acute low back pain, in whom opioids are particularly detrimental. Opioids should be prescribed only after alternative treatments have failed.

7. Potential drug interactions must be evaluated, and opioids should be avoided in patients already taking benzodiazepines, barbiturates, or other narcotics.

8. Patients with chronic pain should receive opioid medications from one practice, preferably their primary care provider or pain specialist. Opioids should be avoided in the emergency department treatment of most chronic conditions. Emergency physicians should coordinate care with a patient’s primary care or pain specialist whenever possible, and previous patient-physician contracts regarding opioid use should be honored.

9. Clinicians should abstain from adjusting opioid dosing regimens for chronic conditions and avoid routinely prescribing opioids for acute exacerbations of chronic noncancer pain.

10. “Long-acting” or “extended-release” opioid products should be avoided for the relief of acute pain.

11. Patients receiving controlled medication prescriptions should be able to verify their identity.

12. Patients who receive opioids should be educated about their side effects and potential for addiction, particularly when being discharged with an opioid prescription.

13. When considering opioids, clinicians should prescribe the lowest possible effective dose in the shortest appropriate duration (eg, <3 days).

14. Emergency departments should refuse to refill lost or stolen opioid prescriptions.

POLICY RECOMMENDATIONS

1. As has been done in other states, the Colorado PDMP should develop an automated query system that can be more readily integrated into electronic health records and accessed by emergency clinicians.

2. Pain control should be removed from patient satisfaction surveys, as they may unfairly penalize physicians for exercising proper medical judgement.

3. Opioid prepacks should be avoided or eliminated in the emergency department if 24-hour pharmacy support is available.

4. Pain should not be considered the “fifth vital sign.”

Jun 08, 2017
Opioid Miniseries Part I: Medicine's Greatest Folly
49:30

The Emergency Medical Minute proudly presents an educational podcast series sponsored by the Colorado Hospital Association addressing our the United States' opioid epidemic.

Jun 07, 2017
Podcast #215: Ankle Pain
04:37

Author: Donald Stader, M.D.

Educational Pearls:

  • The most common ankle injury mechanism is an inversion.
  • Most common broken bone in the ankle is the fibula.
  • During exam, it is important to palpate over the fibular head, medial and lateral malleoli, over the 5th metatarsal and over the cuboid bone. If no tenderness in these areas and the patient is walking - they have a  sprain and can be sent home without imaging.
  • In calcaneal fractures, make sure to image the lumbar spine since up to 30% of calcaneal fractures are associated with lumbar spine injury.

References: http://orthosurg.ucsf.edu/oti/patient-care/divisions/sports-medicine/physical-examination-info/ankle-physical-examination/

Jun 07, 2017
Podcast #214: Dizziness
01:58

Author: Aaron Lessen, M.D.

Educational Pearls:

  • We can differentiate verto into benign problems such as vestibular problem (peripheral problem), or something more worrisome that originates in the brain (central problem).
  • Dizziness + other symptoms makes us think about origination in the CNS.  Symptoms include Dizziness, Diplopia, Dysarthria, Dysphagia, Dysmetria.

References:  http://www.medicalnewstoday.com/knowledge/160900/vertigo-causes-symptoms-treatments

http://www.mayoclinic.org/diseases-conditions/dizziness/basics/causes/con-20023004

 

Jun 05, 2017
Podcast #213: Oats and Potatoes
02:26

Author: Michael Hunt, M.D.

Educational Pearls:

  • Oats have been shown to lower LDL.
  • Oat bran is the most effective way to consume oats to lower LDL.
  • A Swedish study of 69,000 people who ate at least 3 servings of potatoes a week showed no increased risk of a MI or stroke associated with potato consumption.

References: Larsson SC, Wolk A. Potato consumption and risk of cardiovascular disease: 2 prospective cohort studies. Am J Clin Nutr. 2016

Jun 03, 2017
Podcast #212: Knights Who Say Pessary
03:50

Author: Jared Scott, M.D.

Educational Pearls:

  • A pessary is a device inserted into the vagina for medical purposes. Examples include birth control and mechanical support of the pelvic structures.
  • In older women, collapse of the pelvic structures is common, and many may have pessaries to aid in treatment.

References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876320/

Jun 01, 2017
Podcast #211: E-cigarettes
03:28

Author: Michael Hunt, M.D.

Educational Pearls:

  • Children under age of 6 are at greatest risk of accidental nicotine overdose from ingestion.
  • Biphasic presentation:
    • Hyperadrenergic = nausea, vomiting, tachycardia, flushing.
    • Bradycardia and respiratory depression.

References:

http://www.aapcc.org/alerts/e-cigarettes/

Mayer B. How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century. Archives of Toxicology. 2013;88(1):5-7. doi:10.1007/s00204-013-1127-0.

May 31, 2017
Podcast #210: Bear Mauling
04:22

Author: Jared Scott M.D.

Educational Pearls:

  • Bear mauling is not a common issue in the ED.
  • The Ursus americanus (black bear) is the most common in Colorado, but Ursus arctos horribilis (grizzly bear) attacks are more frequent because they are more aggressive.
  • Head and neck lacerations are the most common injuries. Complications include infection and long term PTSD.
  • Most bear attacks are defensive in nature.
  • If a bear attacks you - lay face down and cover your neck with your hands.

References: Frank RC, Mahabir RC, Magi E, Lindsay RL, de Haas W. Bear maulings treated in Calgary, Alberta: Their management and sequelae. The Canadian Journal of Plastic Surgery. 2006;14(3):158-162. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2539044/

May 28, 2017
Podcast #209: Rabbit Done Died
06:24

Author: Sam Killian, M.D.

Educational Pearls:

  • “The Rabbit Has Died” is a lesser used phrase to denote finding out one is pregnant.
  • During a test used in the 1930s, the “Rabbit’s Test,” a rabbit was injected with a potentially pregnant woman’s urine.  If the woman was pregnant, the rabbit would begin displaying signs of pregnancy itself.
  • This test required killing the rabbits to visualize the ovaries, hence the term “Rabbit Done Died”.

References: https://www.early-pregnancy-tests.com/history

May 26, 2017
Podcast #208: Vocal Cord Dysfunction
04:31

Author: Martin O’Bryan M.D.

Educational Pearls:

  • Vocal cord dysfunction can mimic other causes of stridor, such as asthma and upper airway obstruction.
  • Patients are often very anxious because of the difficulty of inspiration.
  • The definitive diagnosis is laryngoscopy that must be done by a pulmonologist.
  • The treatment is general reassurance, asthma medications will not help. CPAP and heliox can be used to help with the stridor.
  • Benzodiazepines can be used to reduce the associated anxiety.

References: https://asthmarp.biomedcentral.com/articles/10.1186/s40733-015-0009-z

May 24, 2017
Podcast #207: Boxer’s Fracture
04:16

Author: Sam Killian, M.D.

Educational Pearls:

  • Defined as fracture of neck (distal segment) of 5th metacarpal.
  • Intrinsic muscles of hand pull segment to palmar aspect of hand.
  • 30 degrees of angulation is allowed. Any more increases risk of chronic pain, grip strength and grasping deficits, and rotational deformities.
  • Reduce fracture if more than 30 degrees of angulation or if rotation is present.
  • Splint fracture in “ulnar gutter” with goal being flexion at MCP and extension at DIP and PIP.

References: http://www.emedicinehealth.com/boxers_fracture/article_em.htm

May 22, 2017
Podcast #206: Urethral Injuries
04:10

Author: Jared Scott, M.D.

Educational Pearls:

  • DDx for blood at urethral meatus includes: pelvic fracture, ruptured bladder, kidney laceration, penile trauma.
  • Retrograde Urethrogram (RUG) must be performed before placing foley and is critical for diagnosis.

References: https://www.ncbi.nlm.nih.gov/pubmed/16488282

May 20, 2017
Podcast #205: Post Cardiac Arrest Temperature Control
03:01

Author: Michael Hunt, M.D.

Educational Pearls:

  • Research has shown that the higher temperatures post-cardiac arrests may lead to poorer outcomes.
  • Initially, 33 deg C was the target temp. However, more research is being done to find therapeutic temperature levels.
  • New studies have shown that the cooling protocol differs for inpatient cardiac arrests vs. outpatient cardiac arrests.   The results show that it may not be necessary to cool inpatient cardiac arrests.

References: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/cardiovascular/therapeutic_hypothermia_after_cardiac_arrest_135,393/

May 18, 2017
Deep Dive #3: The New Standard in Stroke Treatment
38:07

Authors:  Rebecca van Vliet MS, APN; Michelle Whaley MSN, CNS, CCNS, ANVP-VC

The Stroke Team at Swedish Medical Center gives us a taste of how they are breaking records with door-to-needle time in management of acute cerebrovascular accidents.

 

May 16, 2017
Podcast #204: Thoracotomy
02:39

Author: Aaron Lessen M.D.

Educational Pearls:

 

  • Thoracotomy is a potentially life-saving procedure. However, outcomes are often poor and the procedure itself poses many risks to provider and patient.
  • Chance of surviving a thoracotomy when there is no cardiac activity on ultrasound is 0%.
  • Performing a thoracotomy is unlikely to benefit patients with no cardiac activity on ultrasound or patients that lost vital signs greater than 10 minutes before starting the procedure.
  • A thoracotomy is maximally beneficial in patients with a penetrating chest injury that occurred less than 10 minutes before the procedure.

 

References: K. Inaba et al, “FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation” Ann. of Surgery, 2015. https://www.ncbi.nlm.nih.gov/pubmed/26258320

May 14, 2017
Podcast #203: Wine, Milk and… Vaccines!?
04:19

Author: Dave Rosenberg M.D.

Educational Pearls:

  • Louis Pasteur developed the technique that is now known as pasteurization. It was first used in the wine-producing regions of France, and eventually in dairy products like milk.
  • Pasteur also investigated infectious disease. During one experiment, Pasteur’s lab assistant accidentally infected chickens with a weakened form of cholera. When none of the chickens died, Pasteur re-infected them with a stronger strain. This time, none of the chickens became sick because they had been inoculated against the disease. This experiment paved the way for modern vaccination.

References: Smith KA. Louis Pasteur, the Father of Immunology? Frontiers in Immunology. 2012;3:68. doi:10.3389/fimmu.2012.00068.

May 12, 2017
Podcast #202: Tide Pods
03:32

Author: Susan Brion M.D.

Educational Pearls:

  • Laundry and dishwasher detergent pods resemble candy and can be ingested by children.
  • These tide pods are very highly concentrated and can cause chemical burns of the lips, airway, eyes, mouth and esophagus.
  • The strong bases in detergent pods (pH>12) can cause liquefactive necrosis, which can cause immediate perforation of the esophagus.
  • Common symptoms associated with ingestion of detergent pods include pain, dysphagia, drooling, mediastinal pain, upper airway inflammation. The presence or absence of symptoms does not indicate severity - suspected ingestions should be admitted and undergo bronchoscopy.
  • Mental status should be assessed rapidly because detergent ingestion can lead to CNS depression and aspiration.

References: Bonney AG, Mazor S, Goldman RD. Laundry detergent capsules and pediatric poisoning. Canadian Family Physician. 2013;59(12):1295-1296.

May 10, 2017
Podcast #201: Task Interruption
03:56

Author: Mark Kozlowski M.D.

Educational Pearls:

  • Humans cannot “multitask” effectively - a more accurate term is “task interruption.”
  • When doing more than one task at once, we are more likely to forget key details and perform both tasks more slowly overall.
  • Do not interrupt people who are focusing on critical tasks - programming a pump or drawing up doses.
  • Think about ways to reduce task interruption in your hospital for a better clinical practice.

References: Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors. Arch Intern Med. 2010;170(8):683-690. doi:10.1001/archinternmed.2010.65

May 08, 2017
Podcast #200: Non-traumatic Back Pain
02:59

Author: Don Stader M.D.

Educational Pearls:

  • Non-traumatic back pain is a very common complaint in the Emergency Department.
  • Conditions that can manifest with back pain include: ruptured abdominal aortic aneurysm, retroperitoneal bleeding, cauda equina syndrome, epidural abscess or cancer.
  • Patients with cauda equina syndrome or epidural abscess prefer to sit forward, while people with disc issues tend to sit upright.

References: https://emergencymedicinecases.com/episode-26-low-back-pain-emergencies/

 

May 06, 2017
Podcast #199: Prolonged QT with Zofran
03:12

Author: Arthur Lessen M.D.

Educational Pearls:

  • Zofran (ondansetron) is generally safe to use for the treatment of nausea and vomiting. However, it can prolong the QT interval and increase the chance for torsades.

 

  • Low doses of Zofran are not likely to be an issue. However, when multiple doses are given, especially in the setting of a preexisting LQTS, clinical concern should be raised.
  • When giving Zofran to a patient with an increased risk for torsades, consider continuous cardiac monitoring or an alternate anti-emetic.

 

References:  https://www.fda.gov/Drugs/DrugSafety/ucm310190.htm

 

May 04, 2017
Podcast #198: Imodium
03:26

Author: Aaron Lessen M.D.

Educational Pearls:

  • Imodium (loperamide) is a mu-opioid receptor agonist. Traditionally, it is used as an anti-diarrheal. It is also abused recreationally for an opioid high and to self-treat opioid withdrawal.
  • 40 or more pills are often ingested. People often co-ingest with cimetidine to potentiate the desired effects.
  • Patients will present with opioid overdose symptoms (narrow pupils, respiratory depression).
  • Narcan is effective in reversing an overdose of Imodium.
  • Imodium prolongs QT and predisposes to Torsades, so monitor rhythm and then treat like any other opioid OD.

References: http://www.tandfonline.com/doi/abs/10.3109/15563650.2016.1159310

May 02, 2017
Podcast #197: Ashman Phenomenon
01:57

Author: Dylan Luyten M.D.

Educational Pearls:

  • Ashman’s Phenomenon occurs in the setting atrial fibrillation and mimics ventricular tachycardia, but is harmless.
  • On ECG, the pattern of Ashman Phenomenon is a long cycle, followed a short cycle, followed by a complex wide complex beat.
  • The wide complex beats have  right BBB morphology. The long R-R followed by a short R-R leads to conduction down the left bundle branch while the right bundle branch is still in a refractory period.

References: https://lifeinthefastlane.com/ecg-library/atrial-fibrillation/

Apr 30, 2017
Podcast #196: DVT and May-Thurner Syndrome
02:51

Author: Samuel Killian M.D.

Educational Pearls:

  • Lower extremity DVTs are extremely common. There are more left lower extremity DVT due to anatomical variation.
  • May-Thurner Syndrome is a form of anatomical variation in which the left iliac artery compresses the left iliac vein.
  • Anticoagulation may not be sufficient to treat those with May-Thurner syndrome - endovascular stenting may be needed
  • Patients with with recurrent LLE DVT, especially those in whom anticoagulation fails, should be referred to a specialist.

References: Peters M, Syed RK, Katz M, et al. May-Thurner syndrome: a not so uncommon cause of a common condition. Proceedings (Baylor University Medical Center). 2012;25(3):231-233. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377287/

Apr 28, 2017
Podcast #195: How to Properly Inject Heroin
07:11

Author: Don Stader, M.D

Educational Pearls:

  • It is important for providers to know how to use IV drugs properly so that they can instruct their patients on how to avoid injury. Heroin use is increasing.
  • Hepatitis, HIV and infection are possible complications of improper IV drug use
  • The first step of heroin use is to dissolve the solid heroin in water using heat - a spoon and lighter are often used for this step. Next, the heroin is drawn into the syringe through a filter (cotton is often used).
  • Heroin concentration often varies widely - counsel patients to test their heroin first.
  • Sterility of the needle, water, cooker, cotton and syringe is paramount. Refer patients to a needle exchange program where they can get clean supplies.
  • Hepatitis C can live outside the body for 4 days - NEVER share ANY supplies.
  • Sterile procedure is important - needles should not be licked.

References: http://drugsense.org/flyers/10_tips_for_safer_use.pdf

Apr 26, 2017
Podcast #194: Atruamatic ICH
09:33

Author: Peter Bakes, M.D

Educational Pearls

  • Intracerebral hemorrhage is an intracranial bleed within the brain tissue or ventricles.
  • Subarachnoid aneurysm causes about 50% of all ICH.
  • Amyloid deposition can lead to ICH in elderly patients.
  • Hypertension is another common cause of atraumatic ICH, commonly leading to pontine, cerebellar, or basal ganglial bleeding. Bleeding in other locations is suggestive of a different etiology.
  • ICH will often present with depressed mental status, but specifically a patient with a systolic BP > 220 is suggestive of hypertensive ICH.
  • CT is the first diagnostic step. CTA should be considered when the bleeding is in an atypical area. Significant edema on imaging can be suggestive of a tumor.
  • Treatment should include hemostatic measures and BP control. Transfuse platelets if necessary and reverse any anticoagulation. BP target is <140 systolic. Monitor ICP if patient has AMS. Neurosurgical intervention is indicated when there is significant expansion of the hematoma with AMS or if the bleed is cerebellar.

References: Sahni R, Weinberger J. Management of intracerebral hemorrhage. Vascular Health and Risk Management. 2007;3(5):701-709. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291314/

Apr 24, 2017
Podcast #193: The Quick Wee
02:22

Author: JP Brewer M.D.

Educational Pearls:

  • The “Quick Wee” was a method to get urine out of infants who need to have a UA in the Emergency Department.
  • A randomized-controlled experiment was done with 350 infants between the ages of 1 to 12 months.
  • The “Quick Wee” method is taking a sterile saline gauze with cool saline and rubbing it over the suprapubic abdomen for five minutes. The results were significant, with 31% in the treatment group voided after five minutes, 12% in the control group voided after five minutes.

References:  http://www.bmj.com/content/357/bmj.j1341

Apr 22, 2017
Podcast #192: Back Fat Hernia
03:00

Author: Jared Scott M.D.

Educational Pearls:

  • There are two anatomical triangles on the back, the inferior lumbar triangle and the superior lumbar triangle.
  • Herniation occurs whenever something moves to a place where it is not supposed to be, often through a fascial weakness.
  • A “back hernia” can happen when the contents of of the abdominal cavity herniate into the back, usually through the superior lumbar triangle. This is also known as a Grynfeltt-Lesshaft hernia.
  • Back hernias can be traumatic or congenital.
  • These hernias are typically treated surgically.

References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959346/

Apr 20, 2017
Podcast #191: Blunt Cervical Trauma
02:47

Author: Chris Holmes M.D.

Educational Pearls:

  • Mechanism of injury involves hyperextension/hyperflexion
  • Pathophysiology: inside of the arteries in the neck becomes disrupted, similar to a dissection. This is thrombogenic and leads to cerebral infarction
  • Neurologic deficit is common.
  • Other risk factors include facial fracture and cervical-spine fracture.
  • Treat with anticoagulation - aspirin or other antiplatelet agents are appropriate.
  • Increase clinical suspicion when patient presents with neurological deficit and has a negative CT.

References: https://www.east.org/education/practice-management-guidelines/blunt-cerebrovascular-injury

Apr 18, 2017
Deep Dive #2: Biological Terrorism
28:27

Author: Michael Hunt M.D.

Dr. Hunt shares his wealth of experience with biological terrorism over the course of his career.

Apr 16, 2017
Podcast #190: Toradol Dosing
02:21

Author: Rachel Duncan, PharmD BCPS

Educational Pearls:

  • Toradol (Ketorolac) is an NSAID used for its anti-inflammatory properties
  • In practice, the common dosages are 30mg IV or 60mg IM.
  • Clinical concerns arise in patients with renal insufficiency or bleeding, but the risks are small (<1%).
  • Studies have found that doses over 7.5mg have the same efficacy in pain control as higher doses.
  • Consider lower-dose Toradol (15mg) and decrease dose in the elderly and those with a CrCl<50.

References: Motov S, Yasavolian M, Likourezos A, et al. “Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial”. Ann Emerg Med 2016. http://www.annemergmed.com/article/S0196-0644(16)31244-6/fulltext

Apr 14, 2017
Podcast #189: Caffeine
03:59

Author:  Donald Stader M.D.

Educational Pearls:

  • Coffee originates from Ethiopia. Its “active ingredient” is caffeine.
  • Caffeine is a xanthine alkaloid used in medicine to control headache and as a neonatal stimulant.
  • Studies have shown that coffee may increase lifespan.
  • Overdose can be encountered in those using diet pills or concentrated caffeine pills and is treated with dialysis.

References: Juliano, LM et al. “A critical review of caffeine withdrawal: empirical validation of symptoms and signs, incidence, severity, and associated features.” Psychopharmacology, 2004. https://www.ncbi.nlm.nih.gov/pubmed?term=15448977

Apr 12, 2017
Podcast #188: Monoarthritis
05:36

Author: Peter Bakes M.D.

Educational Pearls:

  • Some common causes of monoarticular arthritis include: crystal arthropathies (gout and pseudogout), infection (septic joint), reactive arthritis and acute presentations of chronic arthritides.
  • Lyme disease usually presents with a targetoid lesion associated with constitutional symptoms.
  • The common triad of symptoms associated with reactive arthritis (aka Reiter’s Syndrome) consists of conjunctivitis, urethritis, and arthritis.
  • Reactive arthritis commonly presents with a history of  a GU infection (often chlamydia) or GI infection (Shigella, Campylobacter, Yersinia, Salmonella). It is more common in men and those between 20 and 40 years old.
  • Treatment for reactive arthritis is usually supportive.

References: www.emedicine.medscape.com/article/331347-overview

Apr 10, 2017
Cardiac Arrest Brewcast

Are you super duper sad you missed our event? Did you make it to the event, but want to relive it? Well no worries! We have compiled a summary of the event with some amazing photographs of our speakers in action.

Check it out here: https://emergencymedicalminute.com/?page_id=2578

Apr 05, 2017
Podcast #187: Mumps
04:17

Author: Gretchen Hinson M.D.

Educational Pearls:

  • The key imaging of a mumps patient is “chipmunk cheeks” or parotitis.
  • The swelling can extend almost to the ears and can be extremely painful - in about 25% of cases the swelling is unilateral.
  • Other organs can be involved as well including: testicles, ovaries, breast tissue, other salivary glands, and the brain/spinal cord.
  • Mumps is transmitted through droplets in the air.
  • Two immunizations will get you 88% probability immunity and one immunization will get you 78% probability of immunity. Yet, immunity can wane and there can be viral strains not covered by the immunization.
  • Mumps outbreaks are common in the winter season because of close quarters.
  • You can test for Mumps using an IGM blood test, (more likely to see a spike in this if the patient is not vaccinated) Buckle swabs, & Urine test.

References: https://www.cdc.gov/mumps/index.html

Mar 29, 2017
Podcast #186: IV Contrast
02:22

Author: Aaron Lessen M.D.

Educational Pearls:

  • Regularly a patient’s creatinine level is an important factor in determining whether a patient will receive IV contrast with a CT because it is thought that contrast can harm the kidneys and could worsen underlying kidney disease.
  • A recent retrospective study compared the rates of worsening kidney problems between patients who received a CT scan with contrast, a CT without contrast, and no CT.
  • The study even included patients with creatinines of up to 4 before excluding patients.
  • The study suggested that there is no difference in the rate of worsening kidney problems between the three groups.

References: http://www.annemergmed.com/article/S0196-0644(16)31388-9/fulltext

Mar 21, 2017
Deep Dive #1: Travel Medicine
32:58

Author: Peter Bakes M.D.

Dr. Peter Bakes takes us through how he developed his interest in travel medicine as well as some of the more interesting aspects of the specialty.

Mar 11, 2017
Neuromuscular Blocking Agents
04:38

Author: Peter Bakes

Educational Pearls:

  • The Neuromuscular Junction (NMJ) is a neuronal synapse in skeletal muscle mediated by nicotinic acetylcholine receptors.
  • Paralytic agents, commonly used in the ED for intubation, include succinylcholine and rocuronium/vecuronium.
  • Succinylcholine is a depolarizing paralytic while rocuronium is a non-depolarizing agent.
  • A newly developed reversing agent, sugammadex, can be used to counter the effects of curonium based paralytics.  This is especially helpful due to the long duration of action of rocuronium (45 minutes to 1 hour) as compared to succinylcholine (<15 minutes).

 

References: https://www.acep.org/Physician-Resources/Clinical/Thoracic-Respiratory/Rocuronium-vs--Succinylcholine--Which-Is-Best-/

Mar 10, 2017
Syncope and PE
03:49
There are many causes of syncope and a pulmonary embolism may be a commonly missed reason.
Feb 06, 2017
Electrolyte Emergency
05:11
Electrolytes it's what your bodies crave.
Feb 03, 2017
Aortic Dissection
03:52
What's the difference between an Aortic Dissection and an Aortic Aneurysm?
Feb 01, 2017
Concussions
01:41
New information about concussion precautions for patients
Jan 31, 2017
Lupus Myocarditis
02:52
A case presentation of an abnormal rhythm in a younger patient with Lupus.
Jan 27, 2017
Rectal Prolapse
03:32
Probably not what Def Leppard were thinking about when they wrote "Pour Some Sugar on Me".
Jan 05, 2017
Football Injuries
04:37
Learning about football injuries may not make you a pro bowl player, but it can help you treat patients like one.
Dec 28, 2016
Preeclampsia
06:21
A discussion on the clinical features and testing for preeclampsia in the ER.
Dec 18, 2016
The Cervical Spine
04:43
Are cervical collars disappearing? Probably not soon, but there are a few reasons why collars may not be as helpful as we think.
Dec 13, 2016
Defibrillation
02:58
A few quick tips to help increase the success of defibrillating a patient in persistent ventricular fibrillation.
Dec 07, 2016
CPSSS
03:01
A permutation of the Cincinnati pre-hospital stroke scale to help EMS decide when to take patients to a comprehensive stroke center.
Nov 30, 2016
Reiter's Syndrome
05:36
A unique disease with a bizarre presentation is discussed.
Nov 29, 2016
Spice
02:38
Learn about the dangers of synthetic marijuana and why it is a huge problem for emergency rooms.
Nov 23, 2016
Lyme Disease
07:24
What are the symptoms of Lyme and why is it becoming a more frequent occurrence in the New England and upper Midwest.
Nov 21, 2016
GSW with Neurogenic Shock
03:45
A case of neurogenic shock in patient with a GSW of the spine is discussed.
Nov 16, 2016
Adrenal Glands
03:19
Some of the possible side effects of suppressing or completely removing the adrenal glands.
Nov 04, 2016
Subdural Hematoma
05:51
A discussion about the presentation and treatments for SDH, both chronic and acute.
Oct 28, 2016
TTP
05:08
The clinical presentation of a critical illness that can become fatal if not treated properly.
Oct 25, 2016
Procainamide
02:29
Need a drug to convert a stable wide complex tachycardia patient? Why not procainamide?
Oct 20, 2016
Pregnancy and Radiation
03:12
We all know what a dollar is right? But what about a gray? Let Dr. Scott explain how to approach radiation in pregnancy.
Oct 18, 2016