Contributor: Aaron Lessen, MD Educational Pearls: Recent study at a hospital in Chicago with a shortage of normal saline decided to push IV ceftriaxone rather than the typical infusion of the antibiotic Retrospective chart analysis of about 800 patients to determine safety of giving a push dose of ceftriaxone Only 1 complication due to the ceftriaxone causing a patient to vomit References Agunbiade A, Routsolias JC, Rizvanolli L, Bleifuss W, Sundaresan S, Moskoff J. The effects of ceftriaxone by...
Dec 01, 2021•2 min
Contributor: Nick Hatch, MD Educational Pearls: Inhaled nitric oxide or Flolan may be considered in COVID Flolan is a prostaglandin can be inhaled or given IV These medications are classically used for right-sided heart failure, but may be used in COVID Causes pulmonary vasodilation to reduce the resistance against the right ventricle Complications include hypotension and hemolysis, but nitric oxide can be turned off very quickly if needed Be careful and wean patients on nitric oxide for pulmona...
Nov 30, 2021•6 min
Educational Pearls: Organophosphates affect the cholinergic system by inhibiting acetylcholinesterase affecting muscarinic and nicotinic receptors Symptoms include lacrimation, salivation, bronchoconstriction, blurred vision, bradycardia, bronchorrhea, emesis, and diarrhea Initially, the patient should be decontaminated to prevent further organophosphate exposure Treatment consists of atropine every 5 minutes, 1-3 mg to start and doubling the dose each time it is given until reversal of symptoms...
Nov 23, 2021•5 min
Contributor: Chris Holmes, MD Educational Pearls: Parkland Formula: 4 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours 50% given over 8 hours and 50% given over the next 16 hours Brooke Formula: 2 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours 50% given over 8 hours and 50% given over the next 16 hours 2009 military study evaluated Parkland vs. Brooke formulas for severe burn patients and found the outcomes were the same Guideline...
Nov 22, 2021•5 min
Educational Pearls: Recent updates to treatment guidelines increased the 250 mg ceftriaxone IM dose to 500 mg ceftriaxone IM IM dosing can be very painful, so other methods of administration can help decrease pain for patients Using IV ceftriaxone instead of IM has no significant difference in pharmacokinetics or bioavailability, so it can be considered in patients with an IV already placed References St Cyr S, Barbee L, Workowski KA, et al. Update to CDC's Treatment Guidelines for Gonococcal In...
Nov 16, 2021•4 min
Contributor: Jared Scott, MD Educational Pearls: A press release from Merck introduced Molnupiravir for treatment of mild to moderate COVID-19 The yet to be published study is a randomized control trial at around 100 different sites Reported outcomes were hospitalization and mortality from COVID and mortality from COVID Molnupiravir was found to be twice as effective as placebo looking at these two endpoints (7% vs. 14%) 5 day course of the drug taken twice per day costs $700, but cost-saved fro...
Nov 15, 2021•5 min
Contributor: Nick Tsipis, MD Educational Pearls: Meaningful survival under 10% for out of hospital cardiac arrest The most common cause of out-of-hospital cardiac arrest is due to cardiac ischemia Study looked at whether taking patients without ST elevation who had an out-of-hospital cardiac arrest with return of spontaneous circulation (ROSC) should receive angiography upon arrival to the hospital Took 530 patients and randomized to early vs. delayed angiography after resuscitation from out-of-...
Nov 09, 2021•5 min
Contributor: Aaron Lessen, MD Educational Pearls: Classically, diverticulitis is diagnosed via CT scan and patients are discharged home on antibiotics if they are without complication The DINAMO study is a multicenter open-label RCT that evaluated if it is safe to not give antibiotics to patients with mild acute diverticulitis Found no difference in readmission, return visits to ED, pain control, or likelihood of surgical intervention between the group that was sent home with antibiotics and the...
Nov 08, 2021•4 min
Contributor: Peter Bakes, MD Educational Pearls: Ophthalmia Neonatorum encompasses any conjunctivitis that presents within the first 28 days of life Neonates often receive prophylactic silver nitrate eye drops for gonorrhea prophylaxis, but the drops can cause chemical conjunctivitis Etiology & Timing of Presentation: Silver nitrate conjunctivitis presents 0-2 days after birth Neisseria gonorrhae presents 2-5 days after birth Chlamydia trachomatis presents 5 days to 5 weeks Neisseria gonorrh...
Nov 02, 2021•4 min
Contributor: Aaron Lessen, MD Educational Pearls: Preterm deliveries in the ED can be complex and preventing hypothermia is essential to the health of the baby Recent meta-analysis examined methods for warming preterm deliveries to prevent hypothermia The most effective way to warm the baby is by wrapping them in plastic References Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, et al. Delivery Room Interventions for Hypothermia in Preterm Neonates: A Systematic Review and Network Meta-analysis. ...
Nov 01, 2021•4 min
Contributor: Don Stader, MD Educational Pearls: Ivermectin is a Nobel-Prize winning antiparasitic used to treat filariasis and onchocerciasis Ivermectin is receiving press due to a scientific study examining ivermectin on COVID-19 viral replication in vitro, but the dosages needed for this effect were much higher than is safe for human use Ivermectin has since been studied in humans with no evidence suggesting it is a viable treatment for COVID-19 Ivermectin is a neurotoxin but at normal levels ...
Oct 26, 2021•4 min
Contributor: Alec Coston, MD Educational Pearls: Flash pulmonary edema or Sympathetic Crash Acute Pulmonary Edema (SCAPE) is a severe illness that requires aggressive treatment Often in patients with heart failure and a sympathetic surge increasing heart rate, decreased diastolic filling, increased preload, and increased afterload causing pulmonary edema Clinical diagnosis: acute onset diaphoresis and respiratory distress, hypoxia and tachypnea on exam Bedside lung ultrasound will demonstrate B-...
Oct 25, 2021•5 min
In this podcast, we are back again with host, Jordan Ourada, and neurosurgeon, Dr. Eddie Tsvankin as they discuss an exciting and mind-blowing array of topics pertaining to neurosurgery. Listen as Dr. Tsvankin shares his views on not only the history of neurosurgery, but also the medical, surgical, and engineering advancements that are taking place today. You'll also hear Dr. Tsvankin give intriguing details into how neurosurgeries are performed with cutting-edge technology including the exoscop...
Oct 20, 2021•47 min
Contributor: Donald Stader, MD Educational Pearls: Hip Dislocation Prolonged dislocations can impair blood supply to femoral head Hip dislocation for >6 hours puts patient at high risk for needing a hip replacement in the next two year Knee Dislocation High mechanism Often looks anatomically normal on knee x-ray Vascular injuries of the popliteal artery can cause significant morbidity with some studies suggesting an 80% amputation rate if not treated within 6 hours Ankle Dislocation Common di...
Oct 19, 2021•7 min
Contributor: Dylan Luyten, MD Educational Pearls: To place a Blakemore/Minnesota Tube: Insert into esophagus under visualization Inflate gastric port with 60 cc of air and obtain a chest xray to ensure the balloon below the diaphragm Once confirmed, place a total of 500cc of air into the gastric balloon via the gastric port Tie a liter saline bad to the tube using Kerlix and hang it off an IV pole or other object to provide about 2 lbs of traction Now the the tube is in place under traction, att...
Oct 18, 2021•8 min
On this episode of On The Streets, host, Jordan Ourada sits down with neurosurgeon/neurooncologist Dr. Eddie Tsvankin to discuss various topics concerning neurosurgery and how EMS workers in the field can better understand and manage neurological emergencies. In this episode specifically, you'll hear Jordan and Dr. Tsvankin discuss topics including: Priorities in caring for patients experiencing seizures Short and long-term complications of tumor resection surgery Specifics on how brain tumors a...
Oct 13, 2021•1 hr 5 min
Contributor: Dylan Luyten, MD Educational Pearls: Minnesota Tube has an extra port for suctioning otherwise is the same as a Blakemore Tube Indicated in MASSIVE upper GI bleeding often due to esophageal varices Esophageal varices are dilated, tortuous vessels in the esophagus due to increased portal venous pressure that can bleeding into the upper GI tract Patients with massive upper GI bleed should be intubated prior to placing a Blakemore/Minnesota tube References Meseeha M, Attia M. Esophagea...
Oct 12, 2021•5 min
Contributor: Ricky Dhaliwal, MD Educational Pearls: Multiple RCTs and a Cochrane Review found there is no difference in wound infection rates when irrigating with tap water Pressure of the water and how extensively the wound is irrigated were the most important factors affecting infection rates Quantity and type of water were independently not as important References Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012;(2):CD003861. Published 2012 Feb 15. doi:10....
Oct 11, 2021•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Patients with acute renal failure often need medical management for hyperkalemia Those with severe electrolyte derangements or absent renal function may need emergent dialysis as well Dialysis catheters are 12 or 14 french catheters placed in the right internal jugular or left subclavian Placement is very similar to a central line or cordis catheter Trialysis catheter is one option that has an extra port that can be used for regular medication ad...
Oct 05, 2021•4 min
Contributor: Aaron Lessen, MD Educational Pearls: Hyperkalemia can cause EKG changes such as a widened QRS The fastest electrolyte results can be obtained off a VBG with electrolytes or point-of-care labs Hyperkalemia may be reported as "hemolyzed" which indicated lysis of red blood cells and artificial elevation of the potassium level. However, always keep in mind the clinical context and look at other metabolic abnormalities like creatinine and BUN for other clues that it may actually not be h...
Oct 04, 2021•3 min
Contributor: Nick Tsipis, MD Educational Pearls: Fluid choice may have an impact on outcomes in resuscitation, and a meta-analysis has relevant insight into their use in sepsis and trauma patients Large volume normal saline fluid resuscitation in sepsis is associated with acute kidney injury and metabolic acidosis compared to Lactated Ringers Choice of fluid did not have significant differences in trauma patients for initial resuscitation References Tseng CH, Chen TT, Wu MY, Chan MC, Shih MC, Tu...
Sep 29, 2021•5 min
Contributor: Nick Hatch, MD Educational Pearls: High flow nasal cannula (HFNC) or "heated high flow" can deliver higher oxygen levels than nasal cannula It typically is used as an "intermediate" between oxygen via nasal cannula and other non-invasive positive pressure devices, such as BiPAP Can modify both the FiO2 and flow rate Maximum flow rate is typically 60 liters per minute (compare that to a typical breath that is 30-40 L/min) Humidification of HFNC is important due to risk of epistaxis f...
Sep 27, 2021•5 min
Contributor: Aaron Lessen, MD Educational Pearls: Randomized controlled-trial evaluated intradermal injections of sterile water to manage low back pain versus an IV NSAID Four intradermal injections of 0.1 cc sterile water in a square around the area of musculoskeletal pain Reduction of pain was 7 points with the procedure and 2 points with the IV NSAID at 24 hours 12% in the injection group versus 50% in the IV NSAID group needed opioids 87% patient satisfaction in the injection group versus 16...
Sep 21, 2021•3 min
Contributor: Don Stader, MD Educational Pearls: Those on chronic opioid therapy may have high tolerance to opioids and/or opioid hyperalgesia Ketamine is a good adjunct for pain control in patients on chronic opioid therapy To avoid the time constraints often required to push ketamine intravenously, it can be given orally: Ketamine IV 25-50 mg (~0.01-0.03 mg/kg) as a single dose by mouth References Blonk M, Koder B, et al. Use of oral ketamine in chronic pain management: A review. European Journ...
Sep 20, 2021•4 min
Contributor: Aaron Lessen, MD Educational Pearls: Retrospective cohort study in the Kaiser system looked at over 4 million patients receiving antibiotics to determine the effect of penicillin allergy prompts in the EHR on antibiotic prescribing Half of the sites removed prompts stating penicillin allergy and half kept the prompts Patients with penicillin allergies who received cephalosporins went up from 20% to 27% in areas where the prompt was remove No difference in mortality or no new allergi...
Sep 13, 2021•3 min
Dr. Glenda Quan, trauma surgeon from Swedish Medical Center joins our host Jordan Ourada to review a case of an incorrectly placed IO and how to avoid it. The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account....
Sep 08, 2021•16 min
Contributor: Aaron Lessen, MD Educational Pearls: Insulin pumps provide a continuous infusion of fast-acting insulin using a basal rate and bolus prior to meals Some connect to a continuous glucometer but often blood glucose needs to be checked manually Hypoglycemia is rarely due to a malfunctioning pump - there is usually an another external factor Hyperglycemia can be caused by underdosing, illness, pump malfunction or expired insulin The pump can be used to give a bolus of insulin in the emer...
Sep 07, 2021•5 min
Contributor: Nick Tsipis, MD Educational Pearls: Prospective trial studied 5 mg IM droperidol to 10 mg IM olanzapine (Zyprexa) in the reducing levels of agitation Time to adequate sedation was about 16 minutes for both agents Droperidol was slightly less sedating than olanzapine and length of stay for olanzapine was longer Olanzapine had a higher rate of requiring another agent for adequate sedation Droperidol had a higher rate of adverse events (mainly extrapyramidal symptoms) than olanzapine R...
Aug 31, 2021•5 min
Contributor: Jared Scott, MD Educational Pearls: Using LET, procedural sedation, and distraction techniques are often needed to successfully perform painful procedures in pediatrics patients The technique of clown therapy has been studied as an adjunct to LET and other distraction techniques for procedures in pediatric patients One randomized-controlled trial from 2016 found anxiety was greatly reduced using medical clown therapy to aid in painful procedures in pediatrics patients References Fel...
Aug 30, 2021•5 min
Contributor: Peter Bakes, MD Educational Pearls: Paracentesis is a procedure where fluid is removed from the peritoneal cavity by needle Indications for paracentesis include: large volume paracentesis (5-6L), diagnosis of transudative or exudative ascites, evaluation for spontaneous bacterial peritonitis (SBP) Infection of ascitic fluid is more likely in transudative processes due to the increased frequency of paracentesis E coli is the most common pathogen to cause SBP Treatment with 3rd genera...
Aug 24, 2021•5 min
