Lisa Raville and Dr. Josh Blum, two pioneers of harm reduction in Denver, discuss the addiction crisis, the current state of harm reduction and how it will evolve in the future. Intro Music: Backbay Lounge Kevin MacLeod (incompetech.com) Licensed under Creative Commons: By Attribution 3.0 License http://creativecommons.org/licenses/by/3.0/
Contributor: Erik Verzemnieks, MD Educational Pearls: Important to realize complications can occur in the post-opioid overdose patient regardless of cause Narcan administration has been associated with non-cardiogenic pulmonary edema, although the mechanism of this is not quite known Symptoms include progressive shortness of breath and hypoxia. Treatment is with positive-pressure ventilation and diuresis, similar to cardiogenic causes Though rare, it would appear this typically resolves with tre...
Contributor: Jared Scott, MD Educational Pearls: Non-accidental trauma (NAT) to children is commonly missed by medical providers Try to remember TEN-4-FACES as a useful aide for concerning patterns that may reflect NAT: T orso, e ars, n eck and any bruising in child 4 months or longer F renulum, a ngle of the mandible, c heek, e yes, s clera References Pierce MC, Magana JN, Kaczor K, Lorenz DJ, Meyers G, Bennett BL, Kanegaye JT. The Prevalence of Bruising Among Infants in Pediatric Emergency Dep...
Author: Don Stader, MD Educational Pearls: Suboxone, methadone, and naltrexone are commonly used as treatments for opiate use disorder. Naltrexone is a full mu-opiate receptor antagonist, making acute pain control difficult in patients taking it. Options for pain control in patients on naltrexone include nerve blocks, NSAIDS, ketamine, and high doses of opiates. Of the opiates, Dilaudid (hydromorphone) has the highest affinity for mu-opiate receptors, and will be the most effective. References V...
Author: John Winkler, MD Educational Pearls: The plague (black death) is caused by the Yersinia Pestis bacteria. This bacteria is spread by fleas and carried by rats. It is very contagious and only needs ~ 100 bacteria to cause an infection. The pulmonary form presents with cough, fever, night sweats, hemoptysis and has a near 100% fatality rate if not treated in the first day of symptoms The bubonic form causes buboes, which are necrotic, purulent lymph nodes that can lead to sepsis. Prairie do...
Author: Don Stader, MD Educational Pearls: Abstinence from substances such as tobacco or alcohol are effective strategies to achieve long term sobriety However, abstinence is not an effective strategy for achieving sobriety with opiate use disorder (OUD) Up to 90% of those who use an abstinence-only strategy for OUD will relapse within a month. Attending a rehabilitation facility increases mortality in those with OUD due to decreased tolerance and higher rates of overdose. Medication-assisted th...
Author: Rachel Beham, PharmD Educational Pearls: There are currently many Ebola vaccines that are being studied, and one (recombinant VZV-Ebola vaccine) is currently being used in Africa. This vaccine has so far shown good efficacy in reducing Ebola infections and mortality from Ebola in those who do become infected. There are antibody-based treatments that are currently under investigation for the treatment of Ebola. They have been well tolerated in phase 1 trials and show some promise of effic...
Author: John Winkler, MD Educational Pearls: There is a new outbreak of Ebola in The Congo. This is likely due to civil war and rebel attacks on healthcare workers in the area. Ebola is now spreading from the Congo into neighboring Uganda, but vaccination efforts are staving off the spread across the border Early symptoms of Ebola are similar to the flu Spread occurs through close contact with bodily fluids. Proper PPE is required when treating patients with suspected ebola References https://ww...
Contributor: Jared Scott, MD Educational Pearls: Sleep deprivation and disturbed sleep cycles increases the risk of many acute and chronic medical issues such as motor vehicle accidents, diabetes, cardiovascular disease, psychiatric disease, and shift work sleep disorder (difficulty sleeping, fatigue, interference with daily activities) Stages of sleep Stage 1: 5-10 minutes (light sleep, may not recognize). Stage 2: Spindle waves, mostly unstudied Stage 3: Restorative sleep Stage 4 (REM): Paraly...
Contributor: Chris Holmes, MD Educational Pearls: In ancient Egypt, pregnant women would urinate over barley and wheat seeds to help determine the sex of thier fetus, as well as if they were pregnant. Amazingly, this has 70% accuracy (!!) for determining pregnancy (not sex). Piss Prophets in the middle ages would examine urine for changes in color to determine if a woman was pregnant or not. In the early 1900’s, after discovering progesterone, and it’s associated with pregnancy, the A-Z pregnanc...
Contributor: Nick Tsipis, MD Educational Pearls: Communication proves time and time again to be most helpful in preventing surprises after patient admission Frequent re-evaluations and repeat vital signs can be important to evaluating a patient’s risk for deterioration once admitted as well as selecting the proper level of care at admission Broad categories of patients who most commonly have a change in condition after admission are septic patients and those admitted for respiratory complaints R...
On the first installment of this new series, Dr. Michael Hunt shares stories, lessons and advice as he reflects on his 35 year career as an emergency physician. Intro Music: Backbay Lounge Kevin MacLeod (incompetech.com) Licensed under Creative Commons: By Attribution 3.0 License http://creativecommons.org/licenses/by/3.0/
Contributor : Don Stader, MD Educational Pearls: Seymour fracture is an eponym for a Salter-Harris I/II fracture of the distal phalanx of the finger or toe in children, associated with a nailbed inury These may present and subtle as a subungal hematoma with a fracture on x-ray but carry a significant risk of complications While in adults a hammer-finger deformity indicates an avulsion injury of the extensor tendon, in children it can indicate disruption of the growth plate. This is coupled with ...
Contributor: Don Stader, MD Educational Pearls: Only 10% of patients receiving antibiotics for strep throat actually have the diesease Treatment of strep with antibiotics only slightly reduces the duration of illness. Most studies say the reduction is between 16 and 24 hours Antibiotic treatment may reduce complications such as peritonsilar abscess and otitis media but antibiotics also increase the risk of diarrhea and yeast infection Rheumatic fever is caused by a specific serotype of strep tha...
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Contributor: Don Stader, MD Educational Pearls: The eye is surrounded by relatively inflexible tissues such as the bone of the orbit and the fibrous tissue of the eye. This makes it relatively susceptible to damage from outside compression, which is most common from trauma. This phenomenon is called ocular compartment syndrome (OCS) Look for OCS when patients have face, head or direct eye trauma OCS will present with a swollen, bulging eye associated with pain and blurry vision. Typically diagno...
Contributor: Dylan Luyten, MD Educational Pearls: Those that are hypokalemic are often hypomagnesemic, and should receive magnesium (Mg) supplementation if repleting potassium Mg levels are typically not necessary - if someone is suspect to have hypomagnesemia, just given them Mg Mg increases the AV node refractory period and therefore may be helpful as an adjunct to those in atrial fibrillation with a rapid ventricular response Mg is the preferred treatment for seizure prophylaxis in preeclamps...
Contributor: Aaron Lessen, MD Educational Pearls: Patients with psychiatric complaints are often complicated to disposition from the main ED, and many will require inpatient psychiatric stays Some health systems have dedicated psychiatric ED’s that are specialized in taking care of these patients For example, in Oakland, CA, EMS are permitted to “clear” a patient for transport to a psych-only facility. 5-year retrospective study of this system showed 40% of psych patients were cleared by EMS for...
Author: Jared Scott, MD Educational Pearls: Study from Hennepin County EM studied the efficacy of different drugs for agitation, which included 737 patients Most patients in this study were male and *surprise* drunk Compared doses of common sedatives with primary outcome of sedation at 15 minutes (all intramuscular) haloperidol 5 mg ziprasidone 20 mg olanzapine 10 mg midazolam 5 mg haloperidol 10 mg with the main outcome of agitation at 15 minutes Intramuscular midazolam resulted in the lowest l...
Treatment with buprenorphine is easier, less time consuming and far more effective for management of opioid withdrawal and OUD than standard care with clonidine, IVF, haldol and other symptomatic therapies. Induction with buprenorphine is easy, requires no IV or labs, and is usually accomplished in 1-2 hours. It requires a chair, not a hospital bed. To identify patients who are candidates, be sure they’re in sufficient opioid withdrawal using clinical impression or the COWS scale, obtain a histo...
There are three MAT drugs available to treat addiction: naltrexone (brand name Vivitrol), methadone (brand names Dolophine or Methadose) & buprenorphine (brand name Suboxone, Subutex, and Sublicade). The only MAT drug appropriate for initiation in the ED is buprenorphine. Buprenorphine is a semi-synthetic opioid which acts as partial agonist at the mu receptor. Buprenorphine does not produce as much euphoria or as much of the respiratory depression seen with other opioids. It has a quick onset a...
Medication Assisted Treatment or (Medication for Addiction Treatment) is an important frontier in ED care of patients with Opioid Use Disorder. Naltrexone, methadone and buprenorphine are the medications approved for the treatment of OUD. Addiction is a disease that is widely misunderstood and rarely taught in medical school. It is a dangerous myth that the best treatment of all addictions is simply abstinence. The evolving consensus around OUD is that is best treated with medication. An opioid ...
Addiction is widely misunderstood by the public and by many healthcare providers. It is not taught in most medical schools. Combating the opioid epidemic will require providers to understand Opioid Use Disorder (OUD) and its treatment. Addiction is a chronic, relapsing disease with extraordinarily high morbidity and mortality. It is the transition from controlled to impulsive and compulsive drug intake. Physiologic dependence is just one aspect of addiction. The behavioral and social derangement...
Author: Dave Saintsing Educational Pearls: Poor sleep is an independent risk factor for development of health problems such as type 2 diabetes. A 2019 study, randomized participants to 3 groups: 9 hours of sleep, 5 hours of sleep with weekend catch-up sleep, and 5 hours of sleep without catch-up sleep. In the sleep deprived (5 hour) groups, there was significantly more insulin resistance, calorie intake, and weight gain regardless of catch-up sleep. Tramadol is prescribed 25 million times a year...
Podcast # 499: Posterior Circulation Strokes Contributor: Neal O’Connor, MD Educational Pearls: Dizziness is a very common complaint in the emergency department, but how can we find patients with a dangerous cause of their symptoms, namely a posterior circulation stroke? Consider a posterior circulation stroke in those with an abrupt onset of headache with neck pain, balance problem, blurred vision, or dysphagia Thorough cranial nerve exam can be important to screen for posterior circulation str...
Author: Susan Ryan, DO Educational Pearls: General orthopedic principles: Examine above and below the injury Document neurovascular status X-ray imaging typically requires three different views Fracture description should include name the bone, location of fracture, degree of displacement, and if it is closed or open Osgood-Schlatter (tibia) and Sever’s (calcaneus) disease are apophyseal injuries caused by ligaments that are “stronger” than the bones they attach to When looking for scaphoid inju...
Author: Dylan Luyten, MD Educational Pearls: While certain aspects of the history, exam, and EKG may increase likelihood of ACS, there is no one element that performs well on its own Elements of the history have been found to have different likelihood ratios, which can increase or decrease the probability of a patient having ACS Likelihood ratios greater than one increase the chance of the patient having the disease. Ratios less than one decrease it Bilateral arm radiation is one of very few his...
Author: David Holland, MD Educational Pearls: Hallucinogenics have been used for a variety of cultural and religious reasons for thousands of years In the 1960’s a Harvard professor began experimenting with psilocybin mushrooms. There was resulting public outcry, eventually leading to all hallucinogens being listed as schedule I drugs Common hallucinogens include: LSD (acid), Mescaline (peyote), DMT (ayahuasca), Psilocybin (mushrooms), MDMA (ecstacy) Effects vary by specific drug but may include...
Author: Rachel Brady, MD Educational Pearls: Elderly patients (>65 years old) have a higher trauma mortality compared to younger patients, even though they have lower mechanisms of injury Elder trauma is often under-triaged due to low-energy mechanisms and lack of physiologic response due to age and medications such as beta-blockers. Do not be reassured by normal vital signs. Image elderly patients with head injury aggressively since they are at high risk of intracranial bleeds Be sure to ask ab...
Contributor: JP Brewer, MD Educational Pearls: Obtaining collateral is often vital to determine the potential drugs accessible to the patient - this may include After this, use ancillary sources such as EMS, family/friends, and police to determine the patient’s last normal, PMH and medications To help separate toxidromes , pupillary exam and skin exam are helpful Important physical exam clues in toxicology include the pupils and the skin Adjunct laboratory evaluation may include liver function t...
