Author: Sam Killian, MD Educational Pearls: Patients may have certain fears or expectations about the flu based on hearsay and other less reliable sources Taking extra time explaining the risks of the flu may help base these expectations more in reality This includes providing good return precautions and acknowledging that the disease can still be unpredictable
Author: Michael Hunt, MD Educational Pearls: Use the mnemonic NOT RECLUSE to rule out a brown recluse spider bite: Numerous bites (recluse spiders will bite once) Occurence (recluse bites between April- October) Timing (recluse spiders are… get this… reclusive) Red (recluse bites are white/pale) Elevated (recluse bites are flat) Chronic (recluse bites are acute) Large (recluse wounds are small) Ulceration, early (recluse bites ulcerate between 7-14 days) Swollen (recluse bites are flat) Exudativ...
Author: Nick Tsipis, MD Educational Pearls: Persistent fever or positive blood cultures should raise suspicion for endocarditis Patients with recent dental procedures, recent cardiac surgeries are at risk, or who inject drugs are at higher risk Physical exam findings may include fever with a new murmur, Janeway lesions, Osler nodes, and/or splinter hemorrhages References: Long B, Koyfman A. Infectious endocarditis: An update for emergency clinicians. Am J Emerg Med. 2018 Sep;36(9):1686-1692. doi...
Educational Pearls: Blood concentrations over 0.4 mg/dL is associated with respiratory depression and possible death in alcohol naive patients Alcohol overdose accounts to 2,200 deaths per year Don’t forget about checking for hypoglycemia in severe alcohol intoxication Consider ketamine for agitation to prevent further respiratory depression Editor’s note: check out our podcast on ketamine for alcohol withdrawal here References: Jung YC, Namkoong K. Alcohol: intoxication and poisoning - diagnosi...
Author: Jared Scott, MD Educational Pearls: Blood at urethral meatus in trauma can be a sign of bladder/urethral injury Blind placement of a Foley catheter can make an undiagnosed urethral injury worse Urethral injury is evaluated using a retrograde urethrogram (RUG) If urethra is confirmed to be intact, Foley catheter can be placed to allow additional tests References: Avery, L. (2012). Imaging of male pelvic trauma. Radiologic Clinics of North America., 50(6), 1201-1217....
Author: Sue Chilton, MD Educational Pearls: An unusual cause of leg pain that can mimic sciatica/claudication Predominantly occurring in high endurance athletes, particularly cyclists and runners More common in men Check supine ABIs 1 minute after activity in the ED: a value References: Mansour A, Murney S, Jordan K, Laperna L. Endofibrosis: an unusual cause of leg pain in an athlete. J Sports Med Phys Fitness . 2016 Jan-Feb;56(1-2):157-61. Epub 2015 Jul 3. PubMed PMID: 26140352. Peach G, Schep ...
Author: Gretchen Hinson, MD Educational Pearls: Legionnaires disease refers to a severe pneumonia caused by Legionella pneumophilia and occurs typically at the extremes of age Associated gastrointestinal symptoms (nausea/vomiting/diarrhea) may be present Hyponatremia is a common laboratory finding Legionella urinary antigen can be a convenient test to identify the infection Treatment is with fluoroquinolones, macrolides and/or tetracyclines References Pierre DM, Baron J, Yu VL, Stout JE. Diagnos...
Author: Don Stader, MD Educational Pearls: 8014 patients with out-of-hospital cardiac arrest randomized to epinephrine vs placebo 30-day survival was not dramatically better between groups (3.2%in the epinephrine group and 2.4% in the placebo group) Functional neurological outcome was nearly identical at 2.2% and 1.9% of patients Adds to literature that epinephrine provides little important benefit in cardiac arrest - focus on chest compressions and early defibrillation Editor’s note: NNT for ep...
Author: Jared Scott, MD Educational Pearls: EKG changes do not necessarily correlate to degree of hyperkalemia Traditional progression through peaked T-waves, flattened p-waves, QRS widening, and then sine-waves before asystole References Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721–729....
Author: Erik Verzemnieks, MD Educational Pearls: In the panic of a precipitous ED delivery, remember: Warm. Dry. Stim. It will solve most of your problems in most scenarios Start compressions if heart rate is less than 60 Put the pulse ox on the right hand - it may make a difference as it is preductal Editor’s note: detecting a heart rate can be tough in a newborn - you can feel the umbilical stump or just listen with your stethoscope References Gary Weiner & Jeanette Zaichkin. Textbook of Neona...
Author: Michael Hunt, MD Educational Pearls: Here is a list of some very toxic natural substances: #5: Tetrodotoxin: Found in pufferfish and other aquatic species #4: Ricin: made from castor beans #3: Mercury: natural element absorbable through skin and gloves #2: Batrachotoxin: found on poison dart frogs #1: Botulinum toxin: produced by Clostridium botulinum and causes a descending paralysis Editor's note: batrachotoxin is thought to be accumulated by the beatles and other insects dart frogs ea...
Author: Aaron Lessen, MD Educational Pearls: Non-blinded randomized study assessing 30-day mortality benefit from plasma-first resuscitation in patients at risk hemorrhagic shock Study involved aeromedical transport of trauma patients 30-day mortality 23.2 % in intervention group vs. 33.0% in standard care group Editor's note: a similar study published in Lancet at the same time showed no mortality benefit from prehospital administration of plasma in a slightly different population which had muc...
Podcast # 367: Digital Necrosis after Epinephrine Drip Author: Jared Scott, MD. Educational Pearls: Make sure to monitor for limb ischemia in all patients on vasopressors Good reminder that vasopressors are not risk free - use them only on patients that need them! References Daroca-Pérez, R., & Carrascosa, M. F. . Digital necrosis: a potential risk of high-dose norepinephrine. Therapeutic Advances in Drug Safety . 2017. 8 (8), 259–261. http://doi.org/10.1177/2042098617712669....
Podcast # 366: Ehlers Danlos Author: Gretchen Hinson, MD. Educational Pearls: Heritable mutation in collagen synthesis and expression commonly resulting in joint hyperextension and skin elasticity. Vascular type can result in aneurysm formation and rupture in young patients. Patients are also at risk for spontaneous bowel rupture. Pregnant women can present with uterine rupture. References Byers PH, Murray ML (2012). "Heritable collagen disorders: the paradigm of Ehlers–Danlos syndrome". Journal...
Author: Erik Verzemnieks, MD Educational Pearls: Single study in Japan demonstrated possible effectiveness of renal colic trigger point Patients had injection at the area of maximal tenderness on palpation of the flank Compared to a muscle relaxer, injection of local anesthetic at the trigger point had faster time to pain relief and fewer rescue therapies References Iguchi, M et al. Randomized trial of trigger point injection for renal colic. International Journal of Urology . 2002. 9(9): 475-47...
Author: Peter Bakes, MD Educational Pearls: Pericarditis, LBBB, LVH and left ventricular aneurysms can all present with ST elevation. Ventricular aneurysm will present days after a cardiac event with ST elevation and Q waves in the affected leads. Ventricular aneurysms may cause papillary muscle dysfunction with a resultant holosystolic murmur and even heart failure. References Victor F. Froelicher; Jonathan Myers (2006). Exercise and the heart . Elsevier Health Sciences. pp. 138–. ISBN 978-1-41...
Educational Pearls: Recent study has shown adjunctive ketamine can be useful in setting of alcohol withdrawal. Ketamine was associated with a decrease in the amount of benzodiazepines needed, likelihood of intubation, and a decrease in ICU length of stay by 3 days. For patients with benzodiazepine resistance, ketamine was shown to have symptom relief in an hour and decreased rate of benzodiazepine infusion. References Pizon A, Lynch M, Benedict N, et al. 2018. Adjunct Ketamine Use in the Managem...
Author: John Winkler, MD Educational Pearls: Tall flowering plant with phototoxic sap Direct skin contact with the sap can cause the skin to become photosensitive Severe blisters and even burns can result References Diebel, Matthew (18 June 2018). "Giant Hogweed, a Plant That Can Cause Burns and Blindness, Found in Virginia". USA Today .
Author: Peter Bakes, MD Educational Pearls: Important to find out if patients mean dysequilibrium, lightheadedness, or vertigo when patients say they are “dizzy.” Differentiate central vs. peripheral vertigo Central vertigo typically present with bulbar syndromes (difficulty swallowing, facial nerve palsy) and cerebellar symptoms (ataxia). Peripheral vertigo typically present with sudden onset vertigo with nausea and vomiting in the absence of bulbar symptoms. Episodic? BPPV or Meniere’s Disease...
Author: Dylan Luyten, MD. Educational Pearls: Dangerous causes of back pain: AAA, cauda equina syndrome, epidural abscess. Young person with back pain needs to be evaluated for injection drug use (major risk factor). Patient with focal neurologic deficits (FND) require an MRI. Patients without FND can be screened with ESR and CRP. An ESR Treatment is IV antibiotics and surgical debridement. References Davis DP et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epid...
Author: Sam Killian, MD. Educational Pearls: Computer interpretation has a very good negative predictive value of a normal EKG (99%). Of 222 interpreted as “normal,” 13 were deemed to have some abnormality by a cardiologist in a recent study. Those 13 EKG’s were read by 2 ER docs, and only 1 missed interpretation warranted a move from triage to a bed. References Katie E. Hughes KE., Scott M. Lewis SM., Laurence Katz and Jonathan Jones Safety of Computer Interpretation of Normal Triage Electrocar...
Author: Erik Verzemnieks, MD Educational Pearls: Otic (ear) specific antibiotic drops can be expensive Opthalmic (eye) versions are basically identical and can be used as an affordable substitute as many are on the $4 drug lists But don’t do the reverse (don't use ear drops on the eye) Use caution when administering aminoglycoside if tympanic membrane rupture is present References https://tgtfiles.target.com/pharmacy/WCMP02-032536_RxGenericsList_NM7.pdf http://i.walmart.com/i/if/hmp/fusion/four_...
Author: Michael Hunt, MD Educational Pearls: Toxicity happens from local anesthetics being given too fast, too much, or in the unintended spot Systemic toxicity manifests first with neurologic symptoms like circumoral numbness, tinnitus, blurred vision, nausea, and even seizures. Severe toxicity can then progress to arrhythmias and cardiac arrest. Maximum doses of lidocaine: 4 mg/kg; and with epinephrine: 7mg/kg. Maximum dose of bupivacaine: 2mg/kg; with epinephrine 3mg/kg Editor note: treat sei...
Author: Don Stader, MD. Educational Pearls: A baby can be born dependent on opioids but not addicted to them. Opioid addiction (Opioid Use Disorder) is a disease of mature brains and is characterized by compulsive drug use despite adverse consequences. Opioid addiction is a disease that affects the reward center of the brain Pregnant patients struggling with addiction do better when started on buprenorphine or methadone. This treatment will cause opioid withdrawal syndrome in newborns, but not t...
Author: Aaron Lessen, MD Educational Pearls: Re-emerging STI. Progresses through distinct phases if untreated: Primary syphilis: frequently overlooked because initial chancre is painless. Secondary syphilis: viral syndrome, rash on trunk, palms, and soles. Latent syphilis: asymptomatic period, lasting 5-20 years. Tertiary syphilis: includes neurosyphilis (dementia, encephalitis, etc.) and cardiovascular syphilis (aortitis, etc). Treatment penicillin G 2.4 million units once for primary or second...
Author: Sam Killian, MD Educational Pearls: Hematometra: uterus filled with blood due to obstruction of outflow tract. Most commonly a result congenital abnormalities (imperforate hymen, transverse vaginal septum, etc.) but can be acquired due to cervical stenosis, intrauterine adhesions, neoplasms, and post-surgical scarring. Symptoms include: pain, abnormal bleeding, enlarged uterus Diagnosis: commonly achieved by ultrasound and physical exam. Treatment is surgical (cervical dilatation, hyster...
Author: Sam Killian, MD Educational Pearls: Japan recently approved baloxavir marboxil (Xofluza), which may potentially "kill" Flu A/B within 24 hours Recent RCT trial showed superiority over oseltamavir (Tamiflu) in cessation of viral shedding (24 vs 72 hours) Compared to placebo, superior in time to symptom resolution (53.7 vs 80.7 hours) Administered as single dose Yet to be considered for FDA approval References Portsmouth S, Kawaguchi K, Arai M, Tsuchiya K, Uehara T. Cap-dependent Endonucle...
Podcast #352: TXA for Epistaxis Author: Chris Holmes, M.D. Educational Pearls: TXA: tranexamic acid; used in control of bleeding in major trauma, postpartum hemorrhage, etc. In study of 216 patients with epistaxis, TXA placed on a pledget was compared to anterior cotton nasal packing. The TXA group had faster time to bleeding control, quicker time to discharge, better patient satisfaction, and lower rates of re-bleeding. References: Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. ...
Author: Pete Bakes, MD Educational Pearls: AICD: Automated Implantable Cardioverter-Defibrillator. Can be placed for secondary prevention of cardiac arrest (i.e. history of cardiac arrest not from reversible cause). Also indications for primary prevention: EF 35% or less; ventricular tachycardia with underlying structural heart disease; Brugada; genetic-induced prolonged QT-syndromes. References: Al-Khatib SM et. al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythm...
Author: Nick Hatch, MD. Educational Pearls: A common concern using vasopressors is the risk of digital and mesenteric ischemia. The absolute risk of digital ischemia and/or mesenteric ischemia is pretty low. Norepinephrine at its highest doses carries a 5% digital ischemia rate and a 2% mesenteric ischemia rate. The studies demonstrating this complication were predominately patients with pre-existing liver disease. Providers commonly mistake purpura fulminans, a common complication of sepsis, fo...
