Contributor: Dylan Luyten, MD Educational Pearls: Clear the nasal passages - have the patient, if stable, blow their nose to dislodge any clot that might be in the way Searching for the source of bleeding can be tough. Majority of anterior bleeding is from Kesselbach's plexus Placing a clamp to provide direct pressure is a mainstay of treatment Application of a topical agent, which may include lidocaine epinephrine tetracaine (LET), tranexamic acid (TXA), or oxymetazoline Nasal packing with a na...
Jan 28, 2020•8 min
Contributor: Aaron Lessen, MD Educational Pearls: Emergency department evaluation of falls, particularly in the elderly, should include an assessment of risk factors Common causes of falls in the elderly include medications. Review medication list for sedating medications amongst others Consult with your hospital physical therapist to discuss fall prevention techniques with the patient One study has shown that a comprehensive interdisciplinary approach to geriatric falls in the ED can reduce ret...
Jan 28, 2020•3 min
In the first episode of this new series, the complexities of decision making capacity are discussed. References and Further Reading: [1] Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine , 357 (18), 1834-1840. [2] Etchells, E., Darzins, P., Silberfeld, M., Singer, P. A., McKenny, J., Naglie, G., ... & Strang, D. (1999). Assessment of patient capacity to consent to treatment. Journal of general internal medicine , 14 (1), 27-3...
Jan 22, 2020•10 min
Author: Michael Hunt, MD Educational Pearls: Organophosphate "nerve agents" were developed in the 1930's These agents have cholinergic effects, which can be remembered by the mnemonic "SLUDGE" Salivation Lacrimation Urination Defecation GI cramping Emesis The "SLUDGE" toxidrome is mediated through the muscarinic acetylcholine receptors. Nerve agents also affect the nicotinic acetylcholine receptors, which leads to muscle paralysis Death in these cases is from respiratory collapse due to secretio...
Jan 21, 2020•5 min
Contributor: Dylan Luyten, MD Educational Pearls: Insulin related hypoglycemia can vary from a brief transient effect from short-acting forms (i.e. insulin lispro) to prolonged from long acting (i.e. insulin glargine), and will require different treatment and/or observation Of oral glycemic agents, sulfonylureas are a common culprit while metformin is rarely a cause Sulfonylureas also deserve attention because in pediatric patients, they can be lethal even with a single ingestion, but also can c...
Jan 20, 2020•5 min
Contributor: Jared Scott, MD Educational Pearls: Superior vena cava (SVC) syndrome is caused by physical compression of the SVC and can present with facial swelling, upper extremity swelling, flushing, and parasthesias Common causes of SVC syndrome include lung cancer, lymphoma, and thymoma Keep SVC syndrome on the differential for all patients with facial or upper extremity swelling References The superior vena cava syndrome: clinical characteristics and evolving etiology. Rice TW, Rodriguez RM...
Jan 14, 2020•5 min
Contributor: Don Stader, MD Educational Pearls: The classic migraine cocktail includes: Reglan (or other dopamine antagonist), Benadryl, Toradol, Decadron, and IV fluids. The most effective agent in the cocktail is a dopaminergic agent Routine IV fluids have not shown efficacy There is no evidence for pre-treatment of akathisia with diphenhydramine (Benadryl) Decadron reduces rebound headache Consider trigger point injections for those with migraine attributable to cervical neck pain. References...
Jan 13, 2020•3 min
Contributor: Don Stader, MD Educational Pearls: The common causes of anion gap metabolic acidosis include (MUDPILES) Metformin, Methanol Uremia DKA Paraldehyde INH/Iron Lactate Ethylene Glycol Salicylate Metformin is a very common drug used to treat type 2 diabetes, however in the right setting, it can cause a profound lactic acidosis. There is a very high mortality rate. Treatment of metformin toxicity includes fluids, bicarb, and dialysis Most commonly, metformin toxicity is in the setting of ...
Jan 08, 2020•5 min
Contributor: Aaron Lessen, MD Educational Pearls: Hemophilia is characterized by bleeding (A /B) A is is 8, B (chrstmas, 9) Hemophilia refers to a group of bleeding disorders caused by a deficiency in a certain clotting factor. The two most common are hemophilia A (caused by a lack of factor VIII), and B (caused by a lack of factor 9) Most cases are inherited in an X-linked recessive manner. Therefore, males are the most commonly affected. However, spontaneous cases do occur in all sexes. People...
Jan 08, 2020•3 min
Contributor: Michael Hunt, MD Educational Pearls: Cirrhosis is the end stage of chronic structural damage to the liver. This is most commonly due to alcohol but other causes viral hepatitis and hepatotoxic drugs Cirrhotic patients are very prone to GI bleeding and infections, partially due to the role the liver plays in producing immune and clotting factors These patients can easily become "sick". Use the shock index (heart rate / systolic blood pressure) as a rapid assessment of hemodynamic sta...
Jan 06, 2020•5 min
Contributor: Erik Verzemnieks, MD Educational Pearls: Knee dislocations are most common in high energy trauma, such as a motor vehicle accident The knee may appear grossly normal on initial inspection since dislocations can spontaneously reduce - Look for such findings as hemarthrosis, instability, or ecchymosis, as clues to an occult dislocation. Knee dislocations are often associated with damage to the popliteal artery that runs behind the knee. Assess for pulse deficit on exam. If you are con...
Jan 03, 2020•2 min
Contributor: Charleen Melton, PharmD Educational Pearls: Desmopressin (DDAVP) is an analogue of anti-diuretic hormone (ADH) that has been used for the treatment of intracranial hemorrhage. It works by increasing the release of Von Willebrand factor, helping to stabilize clots. The use of DDAVP for intracranial hemorrhage in patients on antiplatelet agents (mainly Aspirin and Plavix) was recently reviewed In this retrospective review, they found an 88% decreased likelihood of hemorrhage expansion...
Dec 30, 2019•4 min
Contributor: Jared Scott, MD Educational Pearls: The ED is full of painful procedures. One of the most commonly dreaded procedures is nasal packing for epistaxis, as it is quite uncomfortable for the patient. A recent study compared TXA with compression, saline with compression, and traditional nasal packing for the treatment of epistaxis. Hemostasis was achieved in 91% with TXA and compression, 93% with nasal packing, and 71% with saline and compression. There was no statistically significant d...
Dec 24, 2019•3 min
Contributor: Sue Chilton, MD Educational Pearls: More intracardiac devices and injection drug abuse are thought to be increasing incidence of endocarditis Classic signs of endocarditis have included: Osler nodes (pain ful hemorrhagic lesions on hands and feet), Janeway lesions (pain less hemorrhagic lesions on the hands and feet), and splinter hemorrhages in the nail beds Other classic findings like fever and murmur are variable More non-specific symptoms can include flu-like symptoms Patients w...
Dec 20, 2019•4 min
Contributor: Don Stader, MD Educational Pearls: It can be difficult to distinguish between central and peripheral causes of vertigo. Cerebellar stroke should be considered with any dizzy patient. Signs and symptoms that suggest stroke as the cause of vertigo include: ataxia, cranial nerve deficits, and rapid onset of symptoms When cerebellar stroke is being considered, MRI is the imaging modality of choice since CT does not adequately visualize the posterior fossa. References Kim J, Lee H. Verti...
Dec 17, 2019•2 min
Husband and wife Pete and Katie Bakes, both emergency physicians in the Denver-Metro area, reflect on their upbringings, the many lessons learned over their twenty year careers, and how they've evolved as physicians and as a couple in this very special episode of UnfilterED. Time Stamps: 00:25 - Intros 03:05 - How did you two meet? 08:20 - (P) How have you seen Katie develop and change over the course of her medical career? 12:00 - (K) As a young woman, how did you balance your professional aspi...
Dec 14, 2019•1 hr 44 min
Contributor: John Winkler, MD Educational Pearls: Vaping-related lung injury initially presents with flu-like symptoms and can progress to respiratory failure requiring aggressive resuscitation including ECMO It is thought to be related to the contents of homemade vaping fluid, mostly in THC-containing products ("brands" include DankVapes, PaxPen) Ask patients with vague constitutional or respiratory symptoms about their vape use References What are the respiratory effects of e-cigarettes? Gotts...
Dec 10, 2019•3 min
Author: Jared Scott, MD Educational Pearls: A hyphema is blood in the anterior chamber of the eye, typically caused by trauma While there is a spectrum of disease, blurred vision and eye pain are common presenting complaints after direct trauma to the eye Hyphema are graded between Grade 1 and Grade 5, depending on the amount of blood in the anterior chamber. Higher grades are associated with worse outcomes and more complications Other important diagnoses to consider include globe rupture and re...
Dec 05, 2019•2 min
Contributor: Peter Bakes, MD Educational Pearls: Peri-arrest patients present a particular challenge to ED providers, as the differential is broad and time is critical The differential for near cardiac arrest includes the "H's and T's", just as in true cardiac arrest The 6 H's include: hypoxia, hypo/hyperkalemia, hypovolemia (including shock states), hydrogen (acidosis), hypothermia The 6 T's include: tension pneumothorax, cardiac tamponade, thrombus (PE/MI), toxins, trauma Use your history skil...
Dec 03, 2019•8 min
From DU's 1st annual Colorado Behavioral Health and Wellness Summit: Contributor: Michael Miller, Strategic Initiatives Coordinator, Jefferson County Public Health
Nov 27, 2019•57 min
From DU's 1st annual Colorado Behavioral Health and Wellness Summit: Contributors: Judith Shlay, MD, MSPH, Associate Director, Denver Public Health, and Brooke Bender, MPH, Center for Addiction Medicine Planner, Denver Health
Nov 27, 2019•45 min
From DU's 1st annual Colorado Behavioral Health and Wellness Summit: Contributor: Christopher Urbina, MD, MPH, Colorado Consortium for Prescription Drug Abuse Prevention
Nov 27, 2019•1 hr 8 min
From DU's 1st annual Colorado Behavioral Health and Wellness Summit: Contributor: Jason Vitello, MSW, Behavioral Health Coordinator, Denver Public Health/CPHA
Nov 27, 2019•53 min
From DU's 1st annual Colorado Behavioral Health and Wellness Summit: Contributors: Sarah Davidon, EdD, Director of Research & Child and Adolescent Strategy, Mental Health Colorado, and Sarah Younggren, LCSW, Child & Adolescent Specialist, Mental Health Colorado
Nov 27, 2019•1 hr 6 min
From DU's 1st annual Colorado Behavioral Health and Wellness Summit: Contributor: Carl Clark, MD, President & Chief Executive Officer, Mental Health Center of Denver
Nov 27, 2019•23 min
From DU's 1st annual Colorado Behavioral Health and Wellness Summit: Contributor: Karen Prestia, MBA, Director, Marketing & Communications, Mental Health Center of Denver
Nov 27, 2019•33 min
From DU's 1st annual Colorado Behavioral Health and Wellness Summit: Contributors: Allison Miller, LCSW, LAC, Program Manager of Child and Family Outpatient Services, Mental Health Center of Denver, and Jon Roberts, LCSW, CAC II, Licensed Mental Health Therapist, Mental Health Center of Denver
Nov 26, 2019•1 hr 11 min
From DU's 1st annual Colorado Behavioral Health and Wellness Summit: Contributors: Tracy Vozar, Ph.D., Director of the Infant and Early Childhood Mental Health Specialty, and Jennifer M. Tippett, Psy.D., Director of the Substance Use Disorder Specialty, both at the University of Denver's Graduate School for Professional Psychology
Nov 26, 2019•1 hr 6 min
From DU's 1st annual Colorado Behavioral Health and Wellness Summit: Contributors: Marion Rorke, MPH, Substance Use Resource Coordinator, City and County of Denver, and Maggie Kauffman, MPH, Health Equity Data Analyst, City and County of Denver, and Jean Finn, RN, Substance Misuse Manager, City and County of Denver
Nov 26, 2019•32 min
From DU's 1st annual Colorado Behavioral Health and Wellness Summit: Contributors: Lesley Brooks, MD, Chief Medical Officer, Sunrise Community Health Center; Medical Director – Quality, North Colorado Health Alliance, and Heather Ihrig, RN, CO-SLAW Program Director, North Colorado Health Alliance, and Meredith Silverstein, PhD, Sr. Research Associate, Butler Institute for Families, Graduate School of Social Work, University of Denver, and Kali Jefferson, MSW, Research Assistant, Butler Institute...
Nov 26, 2019•20 min
