Author: Aaron Lessen, MD Educational Pearls: Several studies have shown administration of tPA can improve outcomes and reduce need for amputation tPA is considered in grade III and IV frostbite tPA cannot be given until after the warming process Administration is systemically, not catheter directed or intra-arterial References: Jones LM, Coffey RA, Natwa MP, Bailey JK. The use of intravenous tPA for the treatment of severe frostbite. Burns. 2017 Aug;43(5):1088-1096. doi: 10.1016/j.burns.2017.01....
Feb 22, 2019•3 min
Author: Aaron Lessen, MD Educational Pearl: A double ingestion of a single pill is typically a benign event but several drug classes may cause problems A published review of 10 years of single medication double dose ingestion found 12 out of 876 cases had adverse events. The drugs and events were: Propafenone ingestion leading to ventricular tachycardia Beta blocker ingestion leading to bradycardia and hypotension Calcium channel blocker leading to bradycardia and hypotension Bupropion ingestion...
Feb 22, 2019•2 min
Podcast # 437 : Myasthenia Gravis Author: Gretchen Hinson, MD Educational Pearls: Myasthenia gravis (MG) is an antibody mediated autoimmune disorder against the acetylcholine receptors at the neuromuscular junctions. Bimodal age distribution (20’s-30’s: women; 60’s-70’s: men) Presents with fluctuating muscle weakness typically worse at the end of the day with upper extremities affected more than lower and typically involving facial muscles. Myasthenia crisis occurs when muscle fatigue begins to ...
Feb 20, 2019•7 min
Author: Charleen Gnisci, PharmD Educational Pearls: Between 2011 to 2016, Mylan increased EpiPen prices by 400% ($700 for 2 packs) AUVI-Q was recalled in 2012, which left the market share to the EpiPen until recently Teva announced last year it will be making a generic version of the EpiPen retailing around $300 but expected to decrease References: Kaplan, S. F.D.A. Approves Generic EpiPen That May Be Cheaper. The New York Times , The New York Times, 2018. Retrived from www.nytimes.com/2018/08/1...
Feb 18, 2019•3 min
Author: Ryan Circh, MD Educational Pearls: Ulnar collateral ligament injury is often called gamekeeper’s thumb or skier’s thumb Can results from traumatic deviating the thumb radially (abduction) Poor rabbits Have a low threshold for referral to hand surgery for follow up - treatment for minor injuries can be conservative but more severe require surgery to preserve function This injury should be placed in a thumb spica splint Radiographs are often negative unless an avulsion fracture is present ...
Feb 15, 2019•3 min
Author: Peter Bakes, MD Educational Pearl: Transient ischemic attack (TIA) is defined as neurologic symptoms that resolve in 24 hours with no new changes on head imaging Mimics include complex migraine, carotid dissection, seizure (Todd’s paralysis) Typical presentation is with sudden onset of negative symptoms such as numbness, weakness, etc. Mimics tend to have positive symptoms such as photophobia, pain, etc. References: Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention o...
Feb 13, 2019•6 min
Author: Michael Hunt, MD Educational Pearls: Recent study compared ketamine to morphine in elderly patient Ketamine (IV dose 0.3 mg /kg) provided equivalent pain control to morphine (IV dose 0.1 mg / kg) However, etamine group had much higher rate of side effects, including psychoperceptual A lower does of 0.1 mg / kg given intravenously over 15 minutes might be a better option to start in the elderly population - you can always add more! References Motov S, Mann S, Drapkin J, Butt M, Likourezos...
Feb 09, 2019•2 min
Author: Michael Hunt, MD Educational Pearls: As many as 20% of women in assisted living have asymptomatic bacteriuria This can present a diagnostic conundrum when seeing these patients in the emergency department, particularly for altered mental status and deciding whether to treat True diagnosis of UTI in the emergency department is difficult as true diagnoses required culture results and repeated positive samples Procalcitonin is an emerging biomarker that may be helpful in determining the pre...
Feb 07, 2019•4 min
Author: Rachel Brady, MD Educational Pearls: Medication errors are estimated to be the 3rd leading cause of death A 2016 study estimated 250,000 errors occur per year, with 7000-9000 leading to death About 50% are in the ordering/prescribing phase; 25-30% during administration phase. Overworked and distracted providers are the most common underlying reasons for medication error A 2017 study found 40% of ED nurses witnessed a medication error in the last year Editor’s Note: This is a reasonable c...
Feb 04, 2019•3 min
Author: Aaron Lessen, MD Educational Pearls: Choose the longest needle for the humeral IO Internally rotate and adduct the patients hand (resting on umbilicus) for best access to the site Aim 1 cm superior to the greater tuberosity of the humerus with the needle angled 45 degrees inferiorly Maintaining the line is critical - keep arm internally rotated with sling, tape or whatever works References Kovar J, Gillum L. Alternate route: the humerus bone - a viable option for IO access. JEMS. 2010 Au...
Jan 30, 2019•3 min
Author: Chris Holmes, MD Educational Pearls: In WWI, the 2nd leading cause of soldier disability were STDs. An early treatment of syphilis included topical and inhaled mercury Bloodletting, vitriol, arsenic, and bismuth were other treatments for syphilis. Infecting patients with Malaria and treating the Malaria was also tried Thankfully penicillin was discovered for our syphilis woes References Frith J. . Syphilis – Its early history and Treatment until Penicillin and the Debate on its Origins. ...
Jan 28, 2019•4 min
Author: Gretchen Hinson, MD Educational Pearls: Clinical manifestations of severe hypothyroidism may include: Pale, cool, diaphoretic skin Myxedema is the non-pitting edema seen in hypothyroidism Hypothermia, heart failure, hypotension and shock Shortness of breath Cholestasis, constipation Encephalopathy and coma Mortality is 30-50% Specific treatment includes thyroid hormone (T3, T4, or both) and glucocorticoids (for potential adrenal insufficiency) References: Kwaku MP, Burman KD. Myxedema co...
Jan 27, 2019•3 min
Author: Eric Miller, MD Educational Pearls: Recent CDC statement warms against consumption of cookie dough Two common ingredients can pose risk: eggs and flour Flour in dough is a raw agricultural product not treated to kill E. coli A 2016 E. coli outbreak was linked to flour References: https://www.cdc.gov/features/no-raw-dough/index.html https://www.cdc.gov/ecoli/2016/o121-06-16/index.html Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD...
Jan 24, 2019•2 min
Author: Katrina Iverson, MD Educational Pearls: The winter holiday months present a unique picture of patient presentations to the emergency department Some of the unique presentations include: Children falling off Santa’s lap Sledding injuries Falling off ladders Lacerations, ingestion, and insertion of broken ornaments (pediatrics) Parents tend to hurt themselves on their children’s toys References: Lauche R, et al. (2 018). ‘Santa baby, hurry [extra carefully] down the chimney tonight’ – Prev...
Jan 22, 2019•3 min
Author: Aaron Lessen, MD Educational Pearls: Recent meta-analysis reviewed efficacy oseltamivir (Tamiflu) in pediatric populations treated for influenza, showing an 18 hour reduction in duration of illness for those with laboratory confirmed influenza Those with suspected influenza unsurprisingly had less effect Subgroup analysis showed most benefit in those treated within the first 24 hours of symptom onset Patients with confirmed influenza treated with oseltamivir had a 34% reduction in risk o...
Jan 18, 2019•3 min
Author: Mike Hunt, MD Educational Pearls: Measles is highly contagious and successfully infects 90% of those at risk exposed to the virus. 10 day prodrome where patients are asymptomatic. 3 day period of characteristic cough, coryza, conjunctivitis, fever and Koplick spots with a maculopapular rash that moves from head through trunk Infection risk extends three to four days after the onset of rash but also three to four days prior to onset. Have fun with that. A potential exposure, say in an eme...
Jan 16, 2019•4 min
Author: Mike Hunt, MD Educational Pearls: Blunt cardiac injuries most commonly occur in motor vehicle collisions, auto-pedestrian collisions, and from sports injuries The more anterior right ventricle is the most commonly injured structure Look for new EKG changes such as bundle branch blocks, ST changes, or other arrhythmias New EKG abnormalities should prompt consideration of further workup and admission for telemetry Patients may have an elevated troponin - but it is unclear when exactly this...
Jan 14, 2019•4 min
Author: Jared Scott, MD Educational Pearls: From 1996 to 2012, the total quantity of opioids prescribed increased 647% for non-cancer pain Office based prescriptions accounted for 84% of the total opioid prescriptions, up from 64% The total share of opioids prescribed from the emergency department declined from 10% to 3.9% but Total opioids prescribed from the ED still increased 219% over this same time frame References: Axeen S, Seabury SA, Menchine M. Emergency Department Contribution to the P...
Jan 11, 2019•5 min
Author: Gretchen Hinson, MD Educational Pearls: Diabetic ketoacidosis patients are subject to electrolyte derangements Potassium should be monitored closely: K 3.3 K > 5.3 = delay potassium replacement Adult patients are typically severely volume depleted and can require 50 cc/kg bolus or more Insulin typically given in bolus of 0.1 units/kg followed by drip at 0.1 units/kg/hr References: Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglyc...
Jan 09, 2019•4 min
Author: Don Stader, MD Educational Pearls: Recent meta-analysis has demonstrated that there is no significant risk for kidney injury from CT contrast Most kidney injury seen after contrast CTs were due to other underlying illnesses (sepsis, hypovolemia, etc.) Older contrast agents likely did have nephrotoxic effects but this appears to be a thing of the past References: Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR. Acute Kidney Injury After Computed Tomography: A Meta-a...
Jan 07, 2019•2 min
Author: Don Stader, MD Educational Pearls: Etripamil is an intranasal calcium channel blocker in development for use in SVT A recent study showed that etripamil has an SVT conversion rate of around 80% Etripamil does not have the same feeling of “impending doom” that can occur with adenosine Editor's note: Etripamil is still in development and these results are from a phase II clinical trial . References: Stambler BS, Dorian P, Sager PT, Wight D, Douville P, Potvin D, Shamszad P, Haberman RJ, Ku...
Dec 20, 2018•4 min
Author: Don Stader, MD Educational Pearls: Vertebral artery dissection (VAD) contributes to just 2% of strokes overall but ~25% of strokes for patients VAD is associated with minor trauma (chiropractic manipulation, yoga), typically with neck extension and rotation. VAD can cause posterior stroke symptoms (vertigo, diplopia, Horner’s Syndrome , Wallenberg Syndrome ) Overall a good prognosis with around 50% of patients recovering without lasting neurologic deficits. References: Debette S, Leys D....
Dec 17, 2018•3 min
Author: Katie Sprinkle, MD Educational Pearls: Hyponatremia results when patients over hydrate and dilute their sodium with too much free water Symptoms of hyponatremia can mimic symptoms of dehydration (dizziness, lightheadedness, general malaise) With severe hyponatremia patients can progress to seizure, coma, and death Hypernatremia results from dehydration and is more common References: Bennett BL, Hew-Butler T, Hoffman MD, Rogers IR, Rosner MH; Wilderness Medical Society.. Wilderness Medica...
Dec 15, 2018•3 min
Author: Aaron Lessen, MD Educational Pearls: Defined as QRS over 120 ms and rate over 120 Two major rhythms = Vetricular tachycardia (VT) or SVT with aberrancy Safest approach is to assume it is VT Synchronized Cardioversion is preferred even for stable VT for multiple reasons including safety and efficacy Procainamide is preferred pharmacologic option Amiodarone is less preferred third option Calcium channel blockers (i.e. diltiazem) can worsen certain rhythms and should be avoided References: ...
Dec 12, 2018•3 min
Author: Ryan Circh, MD Educational Pearls: Myofascial pain syndrome (MFPS) is typically unilateral with discrete points of palpable pain Often secondary to repeated use and poor posture. MFPS typically responds very well to trigger point injections. Fibromyalgia is bilateral and diffuse and is thought to have a psychological component Some of the best pharmacological treatments for fibromyalgia are Tramadol and Flexeril References: Tofferi JK, Jackson JL, O'Malley PG. Treatment of fibromyalgia w...
Dec 10, 2018•3 min
Author: Dylan Luyten, MD Educational Pearls: Symptoms of acute limb ischemia are the 5 P’s: Pulselessness, pain, pallor, paresthesias, and poikilothermia Sudden onset of non-traumatic extremity pain should raise concern for this diagnosis Obtaining an ankle brachial index (ABI) can help confirm the diagnosis Consultation with vascular surgery should be immediately after the clinical diagnosis and before any further delays to obtain further imaging References: Santistevan JR. Acute Limb Ischemia:...
Dec 08, 2018•4 min
Author: Katie Sprinkle, MD Educational Pearls: The fascia iliaca block is useful for hip and proximal femur fractures. Typically involves injecting 40-60 mL of diluted bupivacaine (0.25%) under the fascia iliaca (or other anesthetic) Anesthesia is achieved of the femoral, obturator, and lateral femoral cutaneous nerves. Monitor for signs of bupivacaine toxicity (paresthesias, AMS, seizures, arrhythmias) Intralipid can be an effective treatment for life-threatening toxicity References: Hoegberg L...
Dec 06, 2018•6 min
Author: Aaron Lessen, MD Educational Pearls: Patients with "minor" strokes with NIHSS 0 to 5 can still end up having poor long-term outcomes Recent study compared use of alteplase vs. aspirin for these patients and saw no difference in regards to favorable neurologic outcome at 90 days Study was ended early due to patient recruitment difficulties Editor's note: though ended early, it is debatable whether even if appropriately powered there would have been an identifiable benefit References: Khat...
Dec 03, 2018•2 min
Author: Dylan Luyten, MD Educational Pearls: Early recognition that the current situation is a mass casualty incident (MCI) is essential with establishing a sole provider/nurse to oversee Team members labeling themselves by name and role is also helpful Practice and prepare for these unfortunate events Editor’s note: This podcast comes at the end of a MCI drill over several days References: http://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooti...
Nov 30, 2018•4 min
Author: Aaron Lessen, MD Educational Pearls: Retrospective study looking at type of transportation and mortality outcomes for patients with penetrating trauma Mortality was 2.2 % for those brought in by private vehicle compared to 11.6% by EMS Editor’s note: the above is raw mortality - even after risk adjustments the odds ratio of death was statistically significant for penetrating injuries, which held true even over multiple trauma systems. Shout out to Dr Haut as well! References: Wandling MW...
Nov 28, 2018•3 min
