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/...
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....
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...
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 ce...
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/...
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 wi...
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....
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: Sin...
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/...
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 pa...
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 a...
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/art...
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 transderm...
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, Amspo...
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...
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 antib...
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 pres...
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...
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...
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...
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...
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....
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...
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 antic...
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 ...
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...
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 ha...
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...
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...
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 Ameri...
