Contributor: Peter Bakes, MD Educational Pearls: Classically presents with the 6Ps: Pain, pallor, paresthesia, pulseless, poikilothermia (cold), and paralysis Acute limb ischemia occurs by embolic or thrombotic causes Thrombotic causes are now more common due to aging populations and advancements in vascular surgery like stents which can be a nidus for thrombosis. Sudden onset of pain without prior symptoms is more typical of embolic causes Preceding symptoms leading to acute ischemia are more o...
Oct 19, 2020•6 min
Capnography is the measurement of the partial pressure of exhaled CO 2 and is an indirect measurement of your cellular respiration. It is displayed visually as a block-like waveform during the exhalation phase of respiration and monitors ventilation in real-time. Capnography is the gold standard for monitoring sedated and intubated patients in the hospital and the field and can be used in many other situations to discern more information about your patient. Our host Jordan Ourada is joined by Dr...
Oct 14, 2020•1 hr 12 min
Contributor: Erik Verzemnieks, MD Educational Pearls: Baclofen is used to treat muscle spasms or spasticity. Baclofen comes in two forms: oral and intrathecal Withdrawal is much more common with those receiving intrathecal administration from a Baclofen pump, which is typically spinal cord patients Withdrawal symptoms usually start within 1-3 days after stopping baclofen Symptoms include altered mental status, muscle rigidity, and fevers, which can mimic other severe illnesses It is nearly impos...
Oct 13, 2020•3 min
Contributor: Don Stader, MD Educational Pearls: F ractures and dislocations that require reduction do not necessarily require sedation Nerve blocks are an effective alternative that can provide analgesia to reduce fractures and dislocations and provide sustained pain relief after the reduction is completed Hematoma blocks are effective for distal radius and various ankle fractures Shoulder dislocations can be reduced by performing a scapular nerve block References Tezel O, Kaldirim U, Bilgic S, ...
Oct 12, 2020•3 min
Contributor: Donald Stader, MD Educational Pearls: Not uncommon for patients presenting after opiate overdose and narcan administration to be observed for 4-6 hours This has been based more on tradition than evidence Observation periods for overdose may vary based on the opiate(s) used Fentanyl and heroin have half lives of about 2 hours, while oxycodone and methadone have significantly longer half lives. HOUR trial attempted to externally validate a scoring tool for stratification of low risk p...
Oct 06, 2020•4 min
Contributor: Sam Killian, MD Educational Pearls: Droperidol (Inapsine) is an antipsychotic drug with efficacy for nausea, vomiting, headaches, and treating agitation In the early 2000’s, Droperidol received a black box warning for QT prolongation This caused a precipitous drop of in administration and ultimately led to a stop in production More careful analysis since has called into question the true incidence of QT prolongation in typical dosing Retrospective review published this year looked a...
Oct 05, 2020•5 min
Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies geared towards mid-level providers at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true when dealing with fevers across different age ranges. With flu season around the corner, now is a good time to brush up on your knowledge surrounding pediatric fevers. D...
Sep 30, 2020•14 min
Contributor: Aaron Lessen, MD Educational Pearls: True allergies to penicillin compared to reported allergies from patients ranges around 10% Recent study took patients undergoing sensitivity tests and developed the PEN(icillin)-FAST score to address reported penicillin allergies PEN-FAST has four components for a total score of 0-4: o F = five years or less since prior reaction. o A = Angioedema/Anaphylaxis. o S = Severe cutaneous reaction (rash). o T = Treatment, did they require treatment for...
Sep 29, 2020•3 min
Contributor: Don Stader, MD Educational Pearls: Local anesthetics injected directly into wounds can cause distortion - especially important in facial lacerations Several blocks can be helpful to help numb branches of the trigeminal nerve (CN V) which innervates the face: Supraorbital nerve block: blocks distribution of V1 (most of the forehead) through injection above the eyebrow External nasal nerve block: blocks superficial innervation of nose through injection along the nasal dorsum Infraorbi...
Sep 28, 2020•5 min
General Counsel attorney, Debi Smith, joins Dr. Nick Tsipis to discuss the ins and outs of healthcare law. Many people forget that a subpoena only compels attendance to a court date, it does not compel one to provide any information on a case without a specific HIPAA compliant authorization for use and disclosure of protected health information. Tune in for more details, perspective on the intricacies of the legal world as it pertains to medicine and for tips on how to navigate different general...
Sep 23, 2020•24 min
Contributor: Aaron Lessen, MD Educational Pearls: Early antibiotics have been shown to improve outcomes in septic patients time after time Emerging evidence challenges the concept of one-size-fits-all large fluid boluses for septic shock patients and fluid may worsen patients who have underlying sepsis-induced pulmonary capillary leak Starting peripheral vasopressors early, and relaxing if fluid resuscitation is successful, is appearing to be a more appropriate strategy than fluids first, then v...
Sep 22, 2020•3 min
Contributor: Sam Killian, MD Educational Pearls: One study found that patients presented with headaches more frequently when there was high temperatures and low humidity, while higher humidity is correlated to lower incidence of headache. Moon phases had no effect on headache frequency. A Canadian study looking at over 100,000 ED visits for headaches found increased incidence of headaches when there were higher levels of air pollution/particulates, like smoke. References Yilmaz M, Gurger M, Ates...
Sep 21, 2020•3 min
Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true for traumatic injuries dealt with in the ED and pre-hospital settings. Dr. Christine Darr, Pediatric Emergency Medicine Physician, discusses a range of traumatic injuries in pediatric patients and how to ...
Sep 16, 2020•25 min
Contributor: Aaron Lessen, MD Educational Pearls: Traditional teaching has shied away from using vasopressors through peripheral IVs Tissue necrosis from extravasation is cited as a risk of use of vasopressors through a peripheral site However, risk of extravasation is low (2-4%) and even more rarely results in significant complications Using an IV that is more proximal and larger bore with monitoring can further minimize these risks Starting with peripheral vasopressors in a critically ill pati...
Sep 15, 2020•3 min
Contributor: Don Stader, MD Educational Pearls: On average, smoking reduces life expectancy by 13.2 years for men and for 14.5 years for women Nicotine is highly addictive and has both stimulant and calming effects Having a newborn can be a strong motivator to quit so take advantage and educate new (or expecting) parents to the risks of smoking and benefits of quitting Smoking has been associated with sudden infant death Biggest predictor of children smoking is seeing their parents smoking Side ...
Sep 14, 2020•3 min
Dr. Glenda Quan, esteemed Trauma Surgeon at Swedish Medical Center, discusses cases related to limb injury and reviews their management. Topics include proper tourniquet application as well as alternatives to commercially available devices how to manage pain or a difficult patient with significant limb injury. We also explore the use of new “hybrid ORs” where multiple surgical teams can care for various injuries simultaneously and briefly chat about the use of blood products in the prehospital s...
Sep 09, 2020•25 min
Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Topical anesthetization can allow for an awake intubation, which substantially decreases chance of loss of airway or respiratory drive because sedatives/paralytics are not necessary Lidocaine treatments like URO-JET (2% lidocaine jelly) can be applied through the nare followed by LMX cream (4% lidocaine) which should be applied to the back of the tongue to anesthetize the tongue and larynx. Good topicalization can be confirmed by testing fo...
Sep 08, 2020•3 min
Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Tranexamic acid (TXA) as shown to have mortality benefit to patients with traumatic GI hemorrhage but should it be used to achieve hemostasis in atraumatic GI bleeding? HALT-IT study looked at TXA for the treatment of upper and lower GI hemorrhage and found no 5 day mortality benefit Patients given TXA also had higher occurrences of DVT and PE References Roberts I, Coats T, Edwards P, et al. HALT-IT--tranexamic acid for the treatment of gas...
Sep 07, 2020•2 min
Contributor: Ramnik Dhaliwal, MD, JD Educational Pearls: Nitrates Nitroprusside: becomes effective in under a minute, and becomes ineffective 10 minutes after stopping it. Nitroprusside can metabolize into cyanide leading to toxicity, however this is rare. Nitroglycerin: predominately causes vasodilation but some arterial dilation as well; preferred agent in patients with volume overload/CHF A drenergic Blocking Agents Labetalol: alpha/beta-blocking agent with a rapid onset of 5 minutes or less ...
Sep 01, 2020•7 min
Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true in the ED and pre-hospital settings. As such, it's important to be careful with the documentation of these patients to maintain accuracy and avoid inclusion of common normal findings that may populate in ...
Aug 31, 2020•11 min
The penicillin and cephalosporin drug classes include many first line drug options for infectious disease although high rates of self-reported allergies may cause physicians to seek alternative options. In part two of our dive into antibiotics use for infectious disease, listen as Dr. Rachael Duncan, Emergency Medicine Clinical Pharmacist, addresses the need to investigate the validity of these reported allergies and their severity to avoid us elf riskier alternatives, like fluoroquinolones. Cro...
Aug 28, 2020•15 min
Trauma and loss are common issues faced by emergency personnel and first responders. These challenges have since been heightened by the COVID-19 pandemic. On this installment of Mental Health Monthly, Anat ‘Nati’ Geva, PsyD, LP joins us to discuss the stages of grief in response to loss and trauma and how they pertain to first responders and frontline workers in particular. Each of the five stages of grief: denial, anger, bargaining, despair and acceptance are addressed and explained so you can ...
Aug 26, 2020•21 min
Contributor: Aaron Lessen, MD Educational Pearls: Carbonated beverages have shown efficacy in helping patients spontaneously pass esophageal food impactions Glucagon, while historically used for treatment, has been shown to have significant side effects without any clinical benefit Definitive treatment is with endoscopy performed typically by a gastroenterologist References Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-B...
Aug 25, 2020•3 min
Contributor: Peter Bakes, MD Educational Pearls: Dental fractures are described by the Ellis classifications, which are based on the involvement of layers of the teeth: Ellis I: involvement of the enamel Ellis II: involvement of the enamel and dentin Ellis III: involvement of the enamel, dentin, and pulp While Ellis I injuries can be sent for dental follow up without intervention, Ellis II/III injuries require covering of the exposed dental layers, particularly because bacteria can more easily e...
Aug 24, 2020•6 min
Welcome to EMM’s first Pharmacy Friday where we dive deeper on a certain pharmacological topic as it pertains to emergency medicine. Dr. Rachael Duncan, emergency medicine clinical Pharmacist, joins us today to talk about antibiotics use for infectious disease, specifically fluoroquinolones. Special thanks to Dr. Nichole Neville, infectious disease pharmacist, for much of the information presented in this podcast. Educational Pearls: Levofloxacin and other fluoroquinolones used to be relied upon...
Aug 21, 2020•19 min
EMM would like to extend a large thank you to the Pain Management and Addiction Medicine section of the American College of Emergency Physicians for allowing us to post their webinar panel discussion facilitated by EMM’s own Don Stader, MD, FACEP on Buprenorphine use after Naloxone. This episode discusses the nuances of emergency physicians inducing patients on Buprenorphine following an opioid overdose and covers key considerations including dosing, precipitated withdrawal and contraindications...
Aug 19, 2020•1 hr 19 min
Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Ventricular Fibrillation (VF) is a potentially fatal cardiac arrhythmia; Refractory VF even more so Epinephrine stimulates alpha and beta receptors which increase sympathetic tone, thereby increasing cardiac oxygen demand and myocardial calcium levels which can cause new arrhythmias, particularly a problem during resuscitation Esmolol (or any beta blocker) can be used in VF refractory to defibrillation, epinephrine and amiodarone in a last-...
Aug 18, 2020•4 min
Contributor: Jared Scott, MD Educational Pearls: Burnout happens. This study reminds us to take a few minutes on shift to take care of yourself. A new study looked at burnout in ER nurses, residents, and attending physicians where they were asked to take a 5-minute break on shift to color or play with a therapy dog. Researchers measured stress levels and checked salivary cortisol levels after the breaks to see if the therapies were working against a control group who did not have the breaks. Tho...
Aug 17, 2020•4 min
Burns are low-volume, high-acuity injuries that require special attention and care from the pre-hospital team to the Emergency Department and finally to a dedicated burn unit and ICU. As a first responder in the pre-hospital setting, there are a couple things that need to remain at the forefront of your mind when dealing with burn patients. On this episode of On the Streets, host Jordan Ourada sits down with Board Certified Plastic Surgeon and Hand Surgeon Dr. Benson Pulikkottil, who is the Medi...
Aug 12, 2020•49 min
Contributor: Don Stader, MD Educational Pearls: Toxic shock syndrome (TSS) is a rare cause of shock typically caused by Staph aureus or Strep pyogenes , that produces a toxin that leads to rapid onset hypotension with a diffuse erythematous rash. Signs of TSS may include rapid onset of altered mental status, dizziness, nausea, abdominal discomfort, hypotension, and rash TSS is associated with foreign bodies, such as tampons or nasal packing - make sure to remove any offending object Clindamycin ...
Aug 11, 2020•7 min
