Contributor: Nick Tsipis, MD Educational Pearls: Acute hyperkalemia is characterized as serum K of 5.4 or higher in non-hemolyzed samples Hyperkalemia is commonly associated with end stage renal disease, acute kidney injury or acute renal failure Cardiac dysrhythmias are the primary concern with hyperkalemia, common EKG changes (and approximate serum levels) can include: Peaked T waves that start to show at serum K of 6 Second sign is lengthening of PR and QRS intervals due to extended repolariz...
Feb 28, 2022•5 min
Dr. Kim Nordstrom, a practicing emergency psychiatrist and associate professor with the University of Colorado, discusses various work-up models alongside valuable bedside tools for elderly patients with acute psychosis. In this podcast, she explores the methods to differentiate primary psychiatric psychosis from medically mediated psychosis in the elderly using an empirical bedside tool. Furthermore, Dr. Nordstrom educates our listeners on the treatment modalities available and currently recomm...
Feb 23, 2022•11 min
Contributor: Nick Tsipis, MD Educational Pearls: Observational study in Israel evaluated cohort of vaccinated pregnant women receiving the initial Pfizer-BioNTech COVID-19 mRNA vaccine Looked at 24,288 newborns with about 16,697 exposed to maternal vaccination in utero Longitudinal follow up showed no significant difference in preterm births, neonatal hospitalizations, post-natal hospitalizations, congenital abnormalities, or mortality While this is not a randomized-controlled trial, this observ...
Feb 22, 2022•3 min
Contributor: Chris Holmes, MD Educational Pearls: Dr. Carl Reinhold August Wunderlich, of the mid-1800s, was the first physician to suggest temperature was related to disease processes and his measurements set the 37˚C (98.6˚F) as the baseline temperature Thermometers were adapted to be sold to the public with guidelines for temperature measurement interpretation Taller and thinner individuals, anyone taking a temperature in the morning, and the elderly have decreased temperatures Temperature av...
Feb 21, 2022•6 min
Contributor: Jared Scott, MD Educational Pearls: ACEP survey was done in 2018 looking at violence towards staff in the ED with only 10% of those solicited responding Survey found 47% of respondents were assaulted and 71% had witnessed violence towards staff Regarding what was done about the violence, 28% said patients were flagged by the hospital, 21% said patient was arrested by police/hospital security, 6% of the cases resulted in the hospital pressing charges, and in 3% of cases the staff wer...
Feb 15, 2022•5 min
Contributor: Peter Bakes, MD Educational Pearls: Tubo-ovarian abscess is a rare complication of pelvic inflammatory disease Usually presents with chief complaint of abdominal pain and is often diagnosed by CT of the abdomen/pelvis Hospitalization is indicated 60-80% of patients improve with an IV anaerobic cephalosporin (cefoxitin or cefotetan) with doxycycline or using clindamycin and gentamicin Mortality can occur in up to 5% of patients, often as a result of progression to septic shock Refere...
Feb 14, 2022•4 min
Contributor: Aaron Lessen, MD Educational Pearls: Normal saline is thought to interfere with renal function and cause an acidosis and balanced fluids (like lactated ringers) are a better option The SALT-ED trial and SMART trial showed a small benefit with renal injury and need for dialysis using balanced fluid in critically ill patients Recent multicenter RCT in Brazil evaluated balanced fluids versus normal saline and looked at 90-day mortality Found no difference in 90-day mortality or seconda...
Feb 08, 2022•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Techniques regarding ring removal in the ED were evaluated in a recent study which looked at using trauma shears versus the motorized ring cutters A certain type of trauma shear has a ring-cutter attached to it, 7 seconds to remove vs. about 70 seconds for motorized ring cutters Both the users of the devices and the patients preferred the ring-cutter shears References Walter J, DeBoer M, Koops J, Hamel LL, Rupp PE, Westgard BC. Quick cuts: A comp...
Feb 07, 2022•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Recent study evaluated budesonide for outpatient COVID-19 infection treatment to see if there was a decrease in length of illness or hospitalization rates Found patients who received a budesonide inhaler had recovery times that were about 3 days shorter and there was a slight (non-significant) decrease in hospitalizations References Berezowski I, Patel J, Shaw M, Pourmand A. High-dose budesonide for early COVID-19. Lancet. 2021;398(10317):2146-21...
Feb 01, 2022•3 min
Contributor: Aaron Lessen, MD Educational Pearls: An endotracheal tube introducer or bougie are often used as a rescue device during difficult intubations as they are small and can be placed blindly Large randomized-controlled trial looked at first-pass bougie use versus standard intubation to determine if there was improvement in first-pass success rate No difference in first-pass success rate, about 80% for both techniques This does not mean that bougies are not great rescue devices or options...
Jan 31, 2022•4 min
Dr. Kim Nordstrom discusses a valuable bedside tool for evidence-based assessment in patients that visit the ED and are at risk for suicidality. Dr. Nordstrom is a practicing emergency psychiatrist and associate professor with the University of Colorado. As a developer and user of the tool, Dr. Nordstrom gives us invaluable insight into a new avenue for psychiatric care in emergency medicine. Educational Pearls: An app-based tool made in conjunction with ACEP Identifying suicidal risk for each p...
Jan 26, 2022•9 min
Contributor: Aaron Lessen, MD Educational Pearls: Think about giving take home naloxone kits for anyone on long-term opioids as well as anyone with an opioid use disorder, those in opioid withdrawal, or those who recently overdosed on opioids Also consider for individuals with non-opioid substance use disorders For patients seen in the ED with an opioid overdose the 1-year mortality is about 5% and 1-month mortality is about 1% Also 50% of accidental pediatric overdose deaths are due to opioids,...
Jan 25, 2022•3 min
Contributor: Nick Tsipis, MD Educational Pearls: Prothrombin complex concentrate (Kcentra) and Vitamin K are used to reverse life-threatening bleeds in patients on warfarin (Coumadin) Factors II, VII, IX, and X are included in four-factor PCC PCC/Kcentra dosing is 500-2000 units based on INR and patient weight PROPER3 RCT was a non-inferiority trial done to evaluate standardized dosing of PCC/Kcentra versus variable dosing based on INR and weight Looked at end-points to assess hemostasis, but ul...
Jan 24, 2022•4 min
Contributor: Nick Hatch, MD Educational Pearls: Botulism requires a prompt clinical diagnosis as lab results can take about 5 days to return Whale blubber, honey, home fermented foods, homemade wine (especially the wine made in prison), and improperly stored canned food can all contain the toxin The botulinum toxin is create by a Clostridium botulinum that is prevalent on our food and in the soil, but the toxin is readily degraded with heat and light Blocks release of acetylcholine at the neurom...
Jan 18, 2022•8 min
Contributor: Ricky Dhaliwal, MD Educational Pearls: Esophageal food impaction can be managed in the ED prior to calling GI for endoscopy Coca-cola, glucagon, benzodiazepines, calcium channel blockers, and dissolved nitroglycerin are all options to try For pediatric patients, weighted bougies can be used under sedation to attempt retrieval of the food bolus Always evaluate airway status, especially if the patient cannot maintain secretions References Long B, Koyfman A, Gottlieb M. Esophageal Fore...
Jan 17, 2022•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Biggest study to date examined new protocol for repeat head CT in anticoagulated elderly patients with head trauma and an initial negative head CT 0.5%-6% of patients in this category will get a delayed ICH and this can occur up to a week out from initial injury 18% of the study group had an ICH on initial head CT, but the rest who had negative head CT initially received a repeat head CT at 6 hours 0.9% had a bleed identified on repeat head CT 6 ...
Jan 11, 2022•4 min
Contributor: Alicia Oberle, MD Educational Pearls: Nitrous oxide (N 2 O) can cause a vitamin B12 deficiency in patients after regular use N 2 O is used in procedural sedation but also as a popular recreational drug N 2 O binds and inactivate B12 in the body, therefore decreasing usable supply Lack of B12, which is essential for myelinating nerves, can lead to subacute combined degeneration of the spinal cord Presentation may include paresthesias, ataxia, gait changes, or bilateral lower extremit...
Jan 10, 2022•3 min
Educational Pearls: Glucagon can be used to treat hypoglycemia and esophageal foreign body, but it can also be used in beta-blocker toxicity to bypass cardiac beta-blockade The superior option for treating bradycardia due to beta-blocker toxicity is glucagon Glucagon has decreased efficacy in patients with heart failure, so increased doses up to 10 mg might be required in the event of beta-blocker toxicity References Khalid MM, Galuska MA, Hamilton RJ. Beta-Blocker Toxicity. [Updated 2021 Jul 26...
Jan 04, 2022•3 min
Contributor: Jared Scott, MD Educational Pearls: A rust ring can occur after a metallic foreign body is left in the eye for a prolonged period of time Issues occur when the rust ring is left as it can epithelialize and become a permanent spot in the patient’s vision An eye burr or Alger brush can help to gouge out the rust ring in the emergency setting These tools have a failsafe mechanism to prevent the eye burr from going through layers past the cornea (though this does not work if the foreign...
Jan 03, 2022•5 min
Contributor: Aaron Lessen, MD Educational Pearls: Pulse checks are necessary during CPR to check for return of spontaneous circulation (ROSC) Previous studies have shown that assessing ROSC with palpating for pulse are not a very consistent Study compared palpating pulses at carotid/femoral artery versus a newly contrived gold standard for pulse checks The gold standard used was an increase in end tidal CO2 + cardiac activity on ultrasound + perfusing rhythm on ECG Carotid artery palpation was t...
Dec 29, 2021•4 min
Contributor: Aaron Lessen, MD Educational Pearls: Study of nearly 400 patients evaluating giving calcium during cardiac arrest with the endpoint as return of spontaneous circulation (ROSC) Compared giving 1 amp calcium chloride with each round of epinephrine for the first two rounds of epinephrine versus saline placebo ROSC occurred in 19% of patients in the calcium groups versus 27% in saline placebo group No magic drugs in cardiac arrest, good CPR and early defibrillation are still the most im...
Dec 28, 2021•2 min
Contributor: Peter Bakes, MD Educational Pearls: High concern causes of third trimester vaginal bleeding include placenta previa, placental abruption, or vasa previa In placenta previa, the placenta implants over the cervix and this condition Often noted during routine prenatal care on transabdominal ultrasound Patients present with painful vaginal bleeding, usually in the absence of trauma Avoid pelvic exam, transvaginal ultrasound, or digital vaginal exam in placenta previa Risk factors for pl...
Dec 21, 2021•4 min
Contributor: Aaron Lessen, MD Educational Pearls: Study examined patient perceptions of providers wearing traditional white coats, fleece coats and soft-shell jackets Found that white coats were seen as more professional than other types of dress Also found that female physicians were viewed as less professional than their male counterparts regardless of dress Older respondents thought more of white coats than younger respondents Patient perspective should be considered and reiterating roles may...
Dec 20, 2021•3 min
Contributor: Ian Gillman, PA-C Educational Pearls: Acute mesenteric ischemia is a condition where bowel loses blood supply from an acute occlusion of the mesenteric arteries A frequent sign is abdominal pain that is out of proportion to the exam Atrial fibrillation is one risk factor for mesenteric ischemia Treatment includes anticoagulation and possible surgical intervention depending on the extent of the ischemia References Monita MM, Gonzalez L. Acute Mesenteric Ischemia. [Updated 2021 Jun 29...
Dec 14, 2021•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Study evaluating patient outcomes after traumatic brain injury (TBI) over 1 year Trial followed patients with severe TBI (GCS 3-8) and moderate TBI (GCS 9-12) At 1 year out ½ of the severe TBI group were able to be independent for at least 8 hours per day; ⅔ were independent to this level at one year in the moderate TBI group ¼ of the patient who were in a vegetative state 2 weeks after the traumatic brain injury had good outcomes at 1 year Refer...
Dec 13, 2021•3 min
Contributor: Adam Barkin, MD Educational Pearls: Seasonal Affective Disorder (SAD) a form of seasonal depression which can result in trouble sleeping, concentration difficulties, changes in appetite, and decreased mood SAD is a common condition affecting millions of people in the US Coupling this with the stresses of COVID, these affects may be compounded To reduce the effects of SAD: Stick to a routine Exercise Light therapy Engage with your community Meditation Tangible bucket list to set goal...
Dec 07, 2021•4 min
Contributor: Aaron Lessen, MD Educational Pearls: End tidal CO2 is accurate to 1-4 mmHg in intubated patient but use with those on positive pressure ventilation like BiPAP is unclear Study looked at patients on BiPAP for COPD or CHF and found end tidal CO2 measurements were significantly underestimated when compared to VBG levels End tidal CO2 measurements for those on positive pressure ventilation appears to be inaccurate References Uzunay H, Selvi F, Bedel C, Karakoyun OF. Comparison of ETCO2 ...
Dec 06, 2021•2 min
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
