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 ...
Nov 26, 2018•4 min
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 a...
Nov 23, 2018•4 min
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 ...
Nov 21, 2018•2 min
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...
Nov 19, 2018•3 min
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 Injur...
Nov 16, 2018•22 sec
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?...
Nov 14, 2018•3 min
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,...
Nov 12, 2018•4 min
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...
Nov 09, 2018•4 min
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, Geor...
Nov 06, 2018•6 min
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, Lagr...
Nov 02, 2018•6 min
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: B NP >...
Oct 31, 2018•4 min
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, Thiruganasambanda...
Oct 29, 2018•2 min
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 Em...
Oct 27, 2018•3 min
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 a...
Oct 24, 2018•4 min
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 att...
Oct 22, 2018•3 min
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 A...
Oct 20, 2018•6 min
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 sa...
Oct 17, 2018•6 min
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 an...
Oct 15, 2018•4 min
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 ...
Oct 12, 2018•7 min
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 ...
Oct 10, 2018•5 min
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 cri...
Oct 08, 2018•4 min
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: ...
Oct 05, 2018•3 min
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 ...
Oct 03, 2018•3 min
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. 201...
Oct 01, 2018•3 min
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,...
Sep 28, 2018•3 min
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...
Sep 26, 2018•3 min
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, Sc...
Sep 24, 2018•4 min
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...
Sep 21, 2018•4 min
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 S...
Sep 19, 2018•3 min
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...
Sep 17, 2018•3 min
