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...
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 Inciden...
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 cock...
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...
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...
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 Calcu...
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, an...
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 ph...
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 comor...
The Emergency Medical Minute proudly presents an educational podcast series sponsored by the Colorado Hospital Association addressing our the United States' opioid epidemic.
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 calca...
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-condi...
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...
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/...
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...
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: F...
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...
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. Referenc...
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. Refere...
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...
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.hopkinsmedicin...
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.
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 b...
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 beca...
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, up...
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, Dunsm...
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-emergenc...
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 ...
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. Im...
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:...
