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 ...
May 02, 2018•4 min
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...
Apr 30, 2018•7 min
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 ca...
Apr 27, 2018•5 min
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(...
Apr 25, 2018•3 min
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 r...
Apr 23, 2018•4 min
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: Wei...
Apr 20, 2018•2 min
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 nystagmu...
Apr 13, 2018•2 min
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/di...
Apr 11, 2018•3 min
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...
Apr 09, 2018•4 min
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 ...
Apr 06, 2018•6 min
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 d...
Apr 04, 2018•5 min
Author: Dr. Peter Bakes Educational Pearls: High risk patients: underlying lung disease, immunocompromised, extremes of age (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 R...
Apr 02, 2018•7 min
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 co...
Mar 30, 2018•5 min
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 prospec...
Mar 28, 2018•2 min
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 caus...
Mar 26, 2018•5 min
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...
Mar 23, 2018•2 min
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...
Mar 21, 2018•3 min
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...
Mar 19, 2018•5 min
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, Schneid...
Mar 16, 2018•3 min
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 expo...
Mar 14, 2018•3 min
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 nost...
Mar 12, 2018•5 min
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 ...
Mar 09, 2018•4 min
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, live...
Mar 07, 2018•3 min
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). C...
Mar 05, 2018•4 min
Since the tragic overdose of his son, Admiral Winnefeld has developed an intriguing strategy on how to combat the Opioid Epidemic.
Feb 27, 2018
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•43 min
Lisa Raville, executive director of The Harm Reduction Action Center in Denver, shares tales from her perspective as a Harm Reductionist.
Feb 16, 2018•10 min
Emergency Medical Minute's very own Donald Stader, MD explains Medicine's contribution to the catastrophe that is the Opioid Epidemic.
Feb 16, 2018•20 min
Dr. Robert Valuck, director of the Colorado Consortium, presents 10 fallacies that have fueled the Opioid Epidemic.
Feb 16, 2018•19 min
The Honorable Alby Zweig shares his impactful first-hand experience with addiction, recovery and triumph.
Feb 16, 2018
