Contributor: Jared Scott, MD Educational Pearls: Pepper spray is a chemical irritant derived from oleoresin capsicum (OC), an extract from pepper plants. It can be used by police for riot or crowd control, or by individuals for self defense. In the event of an exposure, those affected should immediately disperse from the area, remove contact lenses with clean or gloved hands, and remove contaminated clothing. Pepper spray can spread from patients to providers by contact. When caring for those ex...
May 30, 2022•7 min
Contributor: Jared Scott, MD Educational Pearls: About 50% of those infected with SARS-CoV-2 will shed the virus in their feces Wastewater surveillance can be used to track COVID burden, which may be easier than collating test data from multiple hospitals across a region Viral shedding begins 5-7 days prior to symptom onset, so wastewater data can be used to anticipate outbreaks and inform policy and public health initiatives Some existing limitations to wastewater surveillance include: Reportin...
May 24, 2022•5 min
Contributor: Jared Scott, MD Educational Pearls: A study randomized 34 healthy patient to have their left anterior descending artery (LAD) occluded by balloon for 0, 15, 30, or 90 seconds Subsequently, cardiac troponins (cTns) and Copeptin were measured every 15 minutes for 3 hours, then every 30 minutes for the next 3 hours 5 conclusions were drawn: Copeptin is not a useful marker of cardiac ischemia cTn may be detected after only 30 seconds of ischemia cTn may be detected in a little as 15 min...
May 23, 2022•5 min
Contributor: Aaron Lessen, MD Educational Pearls: Tidal volume is the amount of breath a patient receives in a single ventilation Traditional tidal volume (TV) setting was 10 ml/kg but studies showed lower TV had less incidence of respiratory distress, ARDS, and overall better outcomes ED ventilation settings may get carried on for hours or days when a patient is admitted, making this an important part of patient care Recent large systematic review shows that low TV setting in the ED leads to de...
May 17, 2022•3 min
Contributor: Chris Holmes, MD Educational Pearls: Foxglove plant contains the cardiac glycoside digoxin Foxglove leaf potions were once used to treat Dropsy; a historic term for symptoms of heart failure Digoxin, previously used for treating heart failure, works by increases heart contraction strength and slows heart rate Of note, the EKG of patient on digitalis may have a ‘Dali Mustache’ appearance Digoxin toxicity can lead to a variety of dysrhythmias as well as neurological, GI, and metabolic...
May 16, 2022•4 min
Contributor: Aaron Lessen, MD Educational Pearls: Recent study looking at a pediatric emergency department to determine what percentage of patients after intubation received sedation within 10 minutes after intubation About 25% of the patients in the study received sedation within 10 minutes after intubation Only 75% of the patients in the study received sedation in the ED at some point after intubation Those who received rocuronium were less likely to received sedation post-intubation Reference...
May 10, 2022•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Pulse pressure is the difference between the systolic and diastolic blood pressure, normal is about 40 A narrow pulse pressure is generally thought of as less than 30 mmHg which may signal peripheral vasoconstriction in response to lower blood volumes 2020 study examined hypotension and narrow pulse pressure in trauma and outcomes 37% of patients who were hypotensive on ED arrival had a severe injury, 22% of patients who had a narrow pulse pressu...
May 09, 2022•3 min
Contributor: Peter Bakes, MD Educational Pearls: Mild frostbite injury usually only requires supportive care In severe frostbite injury, patients should receive an immediate angiogram, be admitted, and receive tPA if there is evidence of vascular occlusion Salvage rate is around 80% for appropriate patients who receive tPA in phalangeal frostbite injury References Paine RE, Turner EN, Kloda D, Falank C, Chung B, Carter DW. Protocoled thrombolytic therapy for frostbite improves phalangeal salvage...
May 03, 2022•3 min
Contributor: Chris Holmes, MD Educational Pearls: Antiemetics were used in ancient Rome to help with sea-sickness and included toxic substances such as wine and wormwood and white hellborn The first antihistamine used for nausea, dramamine, was introduced in 1947 for motion sickness After this chlorpromazine, prochlorperazine, and promethazine came about in the 1950s and 1960s Cannabis, colloquially referred to as weed, isolates like THC used in the 1970s to help with chemotherapy-induced After ...
May 02, 2022•5 min
In this special episode of MHM, we feature Dr. Nadia Haddad, a Colorado psychiatrist, and Dr. Ricky Dhaliwal, an emergency medicine physician, as they discuss the implications of OUD in Colorado. As a substance use disorder specialist, Dr. Haddad provides an invaluable perspective on various treatment modalities for OUD in the outpatient and inpatient settings. Finally, Dr. Haddad and Dr. Dhaliwal discuss the implications of the newly introduced Colorado legislation affecting patients with OUD a...
Apr 27, 2022•26 min
Contributor: Aaron Lessen, MD Educational Pearls: Traditionally, blood cultures are drawn from two separate sites despite no data to suggest this is better than drawing blood from one site Recent study evaluated multi-site versus single-site blood cultures to determine if there was a difference in accuracy or contamination Positive yield was 20% in the single-site year and 17% in the multi-site year No difference in contamination between the two groups References Ekwall-Larson A, Yu D, Dinnétz P...
Apr 26, 2022•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Olecranon bursitis refers to inflammation in the bursa of the elbow and can be due to infection or trauma Recent study examined treating suspected septic olecranon bursitis with antibiotics versus drainage About 90% of the patients treated with antibiotic therapy for this issue did not require subsequent drainage or hospitalization for intravenous antibiotics Consider treating suspected olecranon bursitis with antibiotic therapy and good return p...
Apr 25, 2022•3 min
On this episode of On the Streets, our host, Jordan Ourada, talks with cardiologist, Dr. Chirag Chauhan, about all things cardiac. Highlighted topics: Wrist versus femoral access in the cath lab The most important prehospital interventions for an MI Nitroglycerin: Who gets it and what are the precautions Lidocaine and amiodarone in a heart attack CPR assist devices
Apr 20, 2022•42 min
Contributor: Chris Holmes, MD Educational Pearls: Maggots were discovered as a therapy to help wound healing in WWI, but this fell out of favor after the discovery of penicillin One study from Israel used maggots in treating diabetic foot wound with positive results but notable patient discomfort Maggots debride tissue, kill MRSA, promote angiogenesis, and promote fibroblast migration to lay down new tissue While maggots may be very useful in wound healing, the reality of the therapy may make pa...
Apr 19, 2022•5 min
Contributor: Aaron Lessen, MD Educational Pearls: Atrial fibrillation is an irregular heart rhythm that sometimes requires rate control in setting of rapid ventricular response (RVR) Calcium channel blocker and beta blockers are the most frequently used medications to block the AV node and slow down the heart rate in atrial fibrillation with RVR If a patient is on one of these agents at home, the IV form should be used first Recent systematic review and meta-analysis found 3 trials addressing wh...
Apr 18, 2022•4 min
Contributor: Aaron Lessen, MD Educational Pearls: Firearms are a dangerous potential method of committing suicide Death occurs in about 5-15% of suicide attempts overall, but death in suicide attempts using firearms occurs in 85-90% of cases In some states, families can petition a judge to remove firearms from a house although healthcare providers cannot do this References Sarai SK, Abaid B, Lippmann S. Guns and Suicide: Are They Related? Prim Care Companion CNS Disord. 2017 Dec 21;19(6):17br021...
Apr 12, 2022•5 min
Contributor: Don Stader, MD Educational Pearls: In a secondary analysis of the PART trial, the mortality effect of timing of airway management for patients in cardiac arrest was examined Study looked at whether timing played a part in both laryngeal tube placement or endotracheal intubation during cardiac arrest Did not find any association of timing and survival to hospital discharge High-quality CPR and defibrillation are the only two things that improve outcomes in cardiac arrest References O...
Apr 11, 2022•4 min
Contributor: Don Stader, MD Educational Pearls: Xylazine, referred to as tranq dope colloquially, is an FDA approved animal tranquilizer that is circulating in the illicit drug markets of the northeastern United states It is a powerful alpha-2 agonist, similar to clonidine, and patients with xylazine overdose may present similarly to opioid overdose Naloxone will not reverse the effects of xylazine and management is supportive care Withdrawal symptoms from xylazine use can be treated with clonid...
Apr 05, 2022•4 min
Contributor: Aaron Lessen, MD Educational Pearls: Hypotension after cardiac arrest often requires a vasopressor to improve blood pressure Recent observational study from France examined outcomes of patients who received either epinephrine or norepinephrine for post-resuscitation shock Norepinephrine had significantly better outcomes Death from shock was 35% in the epinephrine group vs. 9% in the norepinephrine group Recurrent cardiac arrest was 9% in epinephrine group vs. 3% in norepinephrine gr...
Apr 04, 2022•3 min
Contributor: Dr. Kimberly Nordstrom De-escalation usually takes less time than physical and chemical restraints, which leads to decreased injury to staff members, better patient trust and increased patient throughput as accepting facilities oftentimes delay transfer acceptance following physical restraints Prepare to engage prior to entering their room in two ways: cognitively and emotionally Why do you want to de-escalate the patient? Remind yourself you don’t want to introduce more trauma Chec...
Mar 30, 2022•17 min
Contributor: Peter Bakes, MD Educational Pearls: 3% of cases of acute coronary syndrome are due to Takotsubo Takotsubo cardiomyopathy or “broken heart syndrome” can occur with severe physiologic or emotional stressors, as these events can result in a profound outpouring of sympathetic neurotransmitters (epinephrine/norepinephrine) Receptors for these catecholamines are very dense around the apex of the heart, so the apical aspect of the heart can balloon outward as a result of this surge Most of...
Mar 29, 2022•5 min
Contributor: Sam Killian, MD Educational Pearls: Transaminitis refers to the elevation of transaminases, enzymes of the liver (AST and ALT) Elevation of ALT is relatively specific to the liver, but AST is found in more organs than the liver including the muscle If AST is significantly greater than ALT, consider a musculoskeletal origin such as rhabdomyolysis Transaminitis is not always a liver specific issue References Lala V, Goyal A, Minter DA. Liver Function Tests. [Updated 2021 Aug 20]. In: ...
Mar 28, 2022•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Tramadol is often thought of as a mild-opiate to use for analgesia, but it is a more complicated drug Tramadol needs to be metabolized into an effective drug making it not pharmacologically reliable 3-10% of people cannot metabolize tramadol and it does not work Some others over-metabolize tramadol and it causes greater effect Studies have shown it is not any better as a acetaminophen or ibuprofen for analgesia, it can lower a seizure threshold, ...
Mar 22, 2022•4 min
Contributor: Aaron Lessen, MD Educational Pearls: Retrospective cohort study looked at return rate of discharged patients after receiving either phenobarbital or benzodiazepines or both in the ED for treatment of alcohol withdrawal Patients who received benzodiazepines had a 25% chance of returning in 3 days versus a 10% chance of returning in 3 days for those who received phenobarbital 13% of patients returned in 3 days after receiving both phenobarbital and benzodiazepines Phenobarbital may ma...
Mar 21, 2022•2 min
Contributor: Chris Holmes, MD Educational Pearls: Many are taught that patients with cocaine chest pain should not receive beta-blockers due to unopposed alpha agonism, but is this true? 363 consecutive admissions for chest pain with positive cocaine on urine toxicology were reviewed in a retrospective cohort study 60 patients in this cohort received a beta-blocker and multivariate analysis demonstrated a reduction in myocardial infarction risk Another retrospective cohort study demonstrated no ...
Mar 15, 2022•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Septic arthritis can occur at any joint, including the sternoclavicular joint Sternoclavicular joint infections comprise 1% of all bone and joint infections Patients who use intravenous drugs have a higher occurrence of this type of infection compared to the general population, accounting for 17% of all sternoclavicular joint infections Usual treatment includes intravenous antibiotics and, in some cases, surgery References Tapscott DC, Benham MD....
Mar 14, 2022•3 min
Tune in for a double feature with our Equity, Diversity and Inclusion Award winners from this fall as Nick asks them about their backgrounds, what brought them into medicine and Emergency Medicine specifically. Patricia is a 4th year medical student at PennMed. As a first-generation immigrant, college, and medical student, she is committed to actively promoting and being an advocate for diversity, equity, and inclusion because she sees the value in having a diverse workforce to build a more equi...
Mar 09, 2022•51 min
Contributor: Jared Scott, MD Educational Pearls: Variability of organisms in infecting the myocardial valves Duke Criteria for Infective Endocarditis includes three categories that can be used to definitively diagnose endocarditis Pathologic Criteria pathological evidence of infection Major Clinical Criteria positive blood cultures positive echocardiogram findings (TEE is more sensitive than a TTE) Minor Clinical Criteria (must include all of the below criteria) Fever Underlying heart condition ...
Mar 08, 2022•5 min
Contributor: Jared Scott, MD Educational Pearls: Often present with complaints of sore throat, pain with swallowing, difficulty swallowing, voice change, and possible fever Retrospective study from 2018 evaluated outcomes of peritonsillar abscess with two management arms, surgical vs. non-surgical treatment Non-surgical treatment only included IV fluids as well as IV ceftriaxone + clindamycin; Surgical treatment included either needle aspiration or incision and drainage of the abscess as well as...
Mar 07, 2022•7 min
Contributor: Don Stader, MD Educational Pearls: Fentanyl’s common administration route through pills has lowered the psychological barrier of using opioid compared to injecting and smoking heroin Fentanyl is showing up in all illicit drugs with documented cases even in marijuana Testing for fentanyl is difficult and requires a send out test because UA does not show up not common in ED but can better inform our care Fentanyl doesn’t show up on UA drug screen and requires a send out test, thus we ...
Mar 01, 2022•8 min
