Emergency Medical Minute

UNTAMED PART 2: Surviving a Medical Emergency in the Outdoors

UNTAMED PART 1: The Physiology of Experiencing Nature

Podcast #445: Hunting for the endotracheal tube

Author: Michael Hunt, MD Educational Pearls: Bedside transtracheal ultrasound to confirm proper endotracheal intubation is simple and effective Review of 17 studies showed transtracheal ultrasound was was 98.7% sensitive and 97.1% specific Curvilinear probe may be preferable as it provides a larger field of view Editor's Note: rather than explain what you're looking for… just go here References: Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the Confirmation of Endotracheal Tube Intubatio...

Podcast #444: Dyspnea in the intubated patient

Author: Aaron Lessen, MD Educational Pearls: Dyspnea can occur in up to 50% of intubated patients Dyspnea is associated with prolonged mechanical intubation Often goes undiagnosed as these patients have difficulty communicating Expert opinion on reducing sensation of dyspnea Reduce stimulation of respiratory drive like fever and acidosis Give bronchodilators for patients with wheezing Optimize the ventilator settings Use medications for comfort (i.e. opioids, benzodiazepines) References: Decavèl...

Podcast #443: Measles - a timely revisit

Author: Sue Chilton, MD Educational Pearls: Measles is highly contagious Typically patients just look sick Remember 4 & 4, 14, and 4-C's: Contagious 4 days before and after onset of rash 14 days for rash to appear Cough, coryza, conjunctivitis (non-purulent), and Koplik's spots Under 2 and over 20 are highest risk groups 1 in 1000 will die Subacute sclerosing panencephalitis is one of the most feared, degenerative, 100% fatal complications that can occur up to two decades after initial infec...

Podcast #442: When a severe man cold isn't

Author: Jared Scott, MD Educational Pearls: CXR is 40-90% sensitive for detecting pneumonia when compared to CT Patients with a high degree of suspicion for pneumonia may still warrant treatment despite a negative CXR References: Self WH, Courtney DM, McNaughton CD, Wunderink RG, Kline JA. High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patients: implications for diagnosing pneumonia. Am J Emerg Med. 2013 Feb;31(2):401-5. doi: 10.1016/j.ajem.201...

Podcast #441: Is Heparin Worthless for ACS?

Author: Don Stader, MD Educational Pearls: Recent study demonstrated patients with non-STEMI treated with heparin had no difference in survival, but had an increased risk of major bleeding Heparin may be an outdated medication in the era of dual anti-platelet therapy and PCI Heparin may fall to the wayside like other former treatments for ACS such as morphine, oxygen and nitroglycerin as far as mortality benefit References: Chen JY, He PC, Liu YH, Wei XB, Jiang L, Guo W, Duan CY, Guo YS, Yu XP, ...

Podcast # 440 : Carbon Monoxide Poisoning

Author: Katie Sprinkle, MD Educational Pearl: Carbon monoxide (CO) is the leading cause of death from poison world-wide CO forms from the combustion of any carbon based product Patients often present with non specific symptom like headache, vomiting, and malaise Consider this diagnosis with multiple people presenting with similar symptoms from a single location Treatment is with high flow oxygen (i.e. non-rebreather) Hyperbaric therapy is controversial and up for debate - discussion with local c...

Podcast # 438 : tPA for Frostbite

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....

Podcast # 439 : Oops I did it again

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...

Podcast # 437 : Myasthenia Gravis

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 ...

Podcast # 436 : Epinephrine Autoinjectors

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...

Podcast # 435 : UCL Injury

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 ...

Podcast # 434 : TIA

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...

Podcast # 433: Geriatric Ketamine

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...

Podcast # 432: Hunting for UTIs

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...

Podcast # 431: Medication Errors

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...

Podcast # 430: Humeral IO

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...

Podcast # 429: Oldschool Syphilis Treatment

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. ...

Podcast # 428: Severe Hypothyroidism

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...

Podcast # 427: Cookie Dough is Delicious

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...

Podcast # 426: Ho Ho - Oh No!

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. (2018). 'Santa baby, hurry [extra carefully] down the chimney tonight' – Preva...

Podcast # 425: Oseltamivir Efficacy in Children

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...

Podcast # 424: Hunting for Measles

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...

Podcast # 423: Blunt Cardiac Injuries

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...

Podcast # 422: ED Opioid Prescription Trends

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...

Podcast # 421: Sweet DKA Pearls

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 Hyperg...

Podcast # 420: CT Contrast and the Kidneys

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...

Podcast # 419: Etripamil

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...

Podcast # 418: Vertebral Artery Dissection

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....