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 synthe...
Jan 29, 2018•5 min
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 wom...
Jan 26, 2018•4 min
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 injur...
Jan 22, 2018•4 min
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 mi...
Jan 19, 2018•4 min
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 ...
Jan 17, 2018•3 min
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%, r...
Jan 15, 2018•2 min
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 i...
Jan 12, 2018•7 min
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...
Jan 10, 2018•3 min
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 a...
Jan 08, 2018•7 min
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...
Jan 05, 2018•2 min
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...
Jan 03, 2018•4 min
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 identi...
Jan 01, 2018•3 min
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 onb...
Dec 29, 2017•4 min
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. Referenc...
Dec 27, 2017•3 min
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. A...
Dec 25, 2017•4 min
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•30 min
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•3 min
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 ...
Dec 11, 2017•1 min
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•2 min
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...
Dec 06, 2017•3 min
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 ...
Dec 04, 2017•3 min
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 a...
Dec 01, 2017•4 min
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 effec...
Nov 29, 2017•4 min
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://lifeinthef...
Nov 27, 2017•3 min
Author: Sam Killian, M.D. Educational Pearls Difficulty with bag valve mask (BVM) ventilation can be addressed using the MOANS mnemonic. M ask seal, O besity/obstruction, A ge, N o teeth, S leep 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•4 min
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•2 min
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 ...
Nov 13, 2017•3 min
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, Aurba...
Nov 10, 2017•4 min
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, an...
Nov 08, 2017•4 min
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 dram...
Nov 06, 2017•6 min
