Explore every episode of the podcast Emergency Medical Minute
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Title
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Duration
Episode 918: Automated Blood Pressure Cuffs
26 Aug 2024
00:02:53
Contributor: Aaron Lessen, MD
Educational Pearls:
How does an automated blood pressure cuff work?
Automated blood pressure cuffs work differently than taking a manual blood pressure.
While taking a manual blood pressure, one typically listens for Korotkoff sounds (turbulent flow) while slowly deflating the cuff.
An automatic blood pressure cuff only senses the pressure in the cuff itself and specifically pays attention to oscillations in the pressure caused by when the pressure of the cuff is between the systolic (heart squeezing) and diastolic (heart relaxed) pressures.
These oscillations are at a maximum when the pressure in the cuff matches the mean arterial pressure (MAP) and therefore the machines are most accurate at reporting the MAP.
The machines then use the MAP and other information about the oscillations to estimate the systolic and diastolic pressures, which are less accurate.
What should you do if you need more accurate systolic and diastolic blood pressures?
Take a manual blood pressure.
Get an arterial-line (a-line), which provides continuous data for the blood pressure at the end of a catheter.
What happens if the cuff is too big or too small for the patient?
If the cuff is too small it will overestimate the pressure.
If the cuff is too large it will underestimate the pressure.
What should you do if the cuff cycles a bunch of times before reporting a blood pressure?
It probably isn't very accurate so consider another method.
Bonus fact!
The MAP is not directly in the middle of the systolic and diastolic pressures but is weighted towards the diastolic pressure. The MAP can be calculated by adding two-thirds of the diastolic pressure to one third of the systolic pressure. For example if the BP is 120/90 the MAP is 100 mmHg.
References
Benmira, A., Perez-Martin, A., Schuster, I., Aichoun, I., Coudray, S., Bereksi-Reguig, F., & Dauzat, M. (2016). From Korotkoff and Marey to automatic non-invasive oscillometric blood pressure measurement: does easiness come with reliability?. Expert review of medical devices, 13(2), 179–189. https://doi.org/10.1586/17434440.2016.1128821
Liu, J., Li, Y., Li, J., Zheng, D., & Liu, C. (2022). Sources of automatic office blood pressure measurement error: a systematic review. Physiological measurement, 43(9), 10.1088/1361-6579/ac890e. https://doi.org/10.1088/1361-6579/ac890e
Vilaplana J. M. (2006). Blood pressure measurement. Journal of renal care, 32(4), 210–213. https://doi.org/10.1111/j.1755-6686.2006.tb00025.x
Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3
Most common electrolyte abnormalities are hyponatremia and hypokalemia
Heat edema
Caused by vasodilation with pooling of interstitial fluid in the extremities
Heat rash (miliaria)
Common in newborns and elderly
Due to accumulation of sweat beneath eccrine ducts
Heat syncope
Lightheadedness, hypotension, and/or syncope in patients with peripheral vasodilation due to heat exposure
Treatment is removal from the heat source and rehydration (IV fluids or Gatorade)
Heat exhaustion
Patients have elevated body temperature (greater than 38º C but less than 40º C)
Symptoms include nausea, tachycardia, headache, sweating, and others
Normal mental status or mild confusion that improves with cooling
Treatment is removal from the heat source and hydration
Classic heat stroke
From prolonged exposure to heat
Defined as a core body temperature > 40.5º C, though not required for diagnosis or treatment
Presentation is similar to heat exhaustion with the addition of neurological deficits including ataxia
Patients present "dry"
Exertional heat stroke
Prolonged exposure to heat during exercise
Similar to classic heat stroke but the patients present "wet" due to antecedent treatment in ice baths or other field treatments
Management of heat-related illnesses includes:
Cooling
Rehydration
Evaluation of electrolytes
Antipyretics are not helpful because heat-induced illnesses are not due to hypothalamic dysregulation
References
Casa DJ, McDermott BP, Lee EC, et al. Cold water immersion: the gold standard for exertional heatstroke treatment. Exerc Sport Sci Rev 2007; 35:141.
Ebi KL, Capon A, Berry P, et al. Hot weather and heat extremes: health risks. Lancet 2021; 398:698.
Epstein Y, Yanovich R. Heatstroke. N Engl J Med 2019; 380:2449.
Gardner JW, JA K. Clinical diagnosis, management, and surveillance of exertional heat illness. In: Textbook of Military Medicine, Zajitchuk R (Ed), Army Medical Center Borden Institute, Washington, DC 2001.
Khosla R, Guntupalli KK. Heat-related illnesses. Crit Care Clin 1999; 15:251.
Lipman GS, Gaudio FG, Eifling KP, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Heat Illness: 2019 Update. Wilderness Environ Med 2019; 30:S33.
Summarized by Jorge Chalit, OMSIII | Edited by Meg Joyce, MS1
Williams RH, Erickson T, Broussard LA. Evaluating Sympathomimetic Intoxication in an Emergency Setting. Lab Med. 2000;31(9):497-508. https://doi.org/10.1309/WVX1-6FPV-E2LC-B6YG
Summarized by Steven Fujaros | Edited by Jorge Chalit, OMSIII
Podcast 827: Allergies in Peds
07 Nov 2022
00:02:50
Contributor: Aaron Lessen, MD
Educational Pearls:
Recent study evaluated if early exposure to an allergen impacted the rate of allergy development later in childhood
Children were exposed to peanut, milk, wheat, and egg allergens at 3 months of age and then followed for 3 years
2.5-3% of children who were not exposed developed allergies to these allergens
1% of children exposed to the allergens developed allergies to these allerrgens
Exposing 63 children to allergens at 3 months would prevent the development of food allergy in one child with no significant adverse events
Future recommendations will likely be to gradually introduce allergens to children starting around 3 months
References
Skjerven HO, Lie A, Vettukattil R, et al. Early food intervention and skin emollients to prevent food allergy in young children (PreventADALL): a factorial, multicentre, cluster-randomised trial. Lancet. Jun 25 2022;399(10344):2398-2411. doi:10.1016/s0140-6736(22)00687-0
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
The presence of a STEMI has traditionally been used to determine if a patient with acute chest pain requires urgent cath lab management
STEMI indicates an occluded coronary artery, and urgent intervention is needed to restore perfusion to ischemic tissue
Patients with occluded coronary arteries can present with EKG findings other than STEMI
2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department was recently published in the Journal of the American College of Cardiology
Recognizes STEMI equivalents that necessitate cath lab management
ST depression in precordial leads
Indicates a posterior infarct/possible RCA occlusion
LBBB c ST elevation meeting modified Sgarbossa criteria
Hyperacute and/or De Winter T wave
First indication of coronary artery occlusion
Most beneficial time to initiate cath lab because more tissue is salvageable
These recommendations will likely alter clinical practice for ED management of acute chest pain
References
Kontos MC, de Lemos JA, Deitelzweig SB, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. Oct 6 2022;doi:10.1016/j.jacc.2022.08.750
Meyers HP, Bracey A, Lee D, et al. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med. Mar 2021;60(3):273-284. doi:10.1016/j.jemermed.2020.10.026
Tziakas D, Chalikias G, Al-Lamee R, Kaski JC. Total coronary occlusion in non ST elevation myocardial infarction: Time to change our practice? Int J Cardiol. Apr 15 2021;329:1-8. doi:10.1016/j.ijcard.2020.12.082
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
In urban settings, it is becoming more common for police to transport critical patients from scene to hospital
A 2022 multicenter observational study compared mortality rates in patients with penetrating injury to torso and/or proximal extremity when transported by EMS versus police
Approximately 18% of patients were transported by police
Overall mortality was approximately 15% in both groups
In patients with more severe injury, mortality was still similar at approximately 36% and 38% respectively
References
Taghavi S, Maher Z, Goldberg AJ, et al. An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients. J Trauma Acute Care Surg. 2022;93(2):265-272. doi:10.1097/TA.0000000000003563
Jacoby SF, Branas CC, Holena DN, Kaufman EJ. Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma. Trauma Surg Acute Care Open. 2020;5(1):e000541. Published 2020 Nov 26. doi:10.1136/tsaco-2020-000541
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MS4 & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Catheter related blood infections were thought to be caused by skin flora seeding the catheter. Thus, significant effort is applied to sterility and skin preparation.
However, studies have shown that bacteria growing on the tip of the catheter is not consistent with growth on cultures of skin.
Staphylococcus epidermidis is commonly found on cultures of catheter sites. It has also been found in the gut flora of >50% of ICU patients. Rates of catheter related blood infections have been decreased through oral decontamination and early feeding.
These findings suggest enteral bacterial translation as a major source of blood stream infection.
References
O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162-e193. doi:10.1093/cid/cir257
von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group. N Engl J Med. 2001;344(1):11-16. doi:10.1056/NEJM200101043440102
ALTEMEIER WA, HUMMEL RP, HILL EO. Staphylococcal enterocolitis following antibiotic therapy. Ann Surg. 1963;157(6):847-858. doi:10.1097/00000658-196306000-00003
Marshall JC, Christou NV, Horn R, Meakins JL. The microbiology of multiple organ failure. The proximal gastrointestinal tract as an occult reservoir of pathogens. Arch Surg. 1988;123(3):309-315. doi:10.1001/archsurg.1988.01400270043006
Mrozek N, Lautrette A, Aumeran C, et al. Bloodstream infection after positive catheter cultures: what are the risks in the intensive care unit when catheters are routinely cultured on removal?. Crit Care Med. 2011;39(6):1301-1305. doi:10.1097/CCM.0b013e3182120190
Atela I, Coll P, Rello J, et al. Serial surveillance cultures of skin and catheter hub specimens from critically ill patients with central venous catheters: molecular epidemiology of infection and implications for clinical management and research. J Clin Microbiol. 1997;35(7):1784-1790. doi:10.1128/jcm.35.7.1784-1790.1997
Tani T, Hanasawa K, Endo Y, et al. Bacterial translocation as a cause of septic shock in humans: a report of two cases. Surg Today. 1997;27(5):447-449. doi:10.1007/BF02385710
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MS4 & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Immediate resuscitative thoracotomy can be performed in the ED to gain rapid access to the thoracic cavity in cases of traumatic cardiac arrest
Western Trauma Association Society Criteria for ED thoracotomy
Blunt trauma + <10 min of prehospital CPR
Penetrating trauma to torso + <15 min prehospital CPR
Penetrating trauma to the neck/extremity + <5 min prehospital CPR
Signs of life with refractory shock can consider resuscitative thoracotomy
Outcomes in immediate resuscitative thoracotomy are poor but are improving
A recent study evaluated over 2,000 patients meeting inclusion criteria for immediate resuscitative thoracotomy
Overall survival rate of 20%
26% survival rate in penetrating trauma
7% survival rate in blunt trauma
Predictors for poor outcomes
Patient age > 60 years
Blunt trauma mechanism of injury
A prehospital or ED HR <60 bpm
Absent signs of life at time of ED arrival
When criteria are met, immediate resuscitative thoracotomy should rapidly be performed in the ED
References
Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359-1363.
Panossian VS, Nederpelt CJ, El Hechi MW, et al. Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility. J Surg Res. 2020;255:486-494.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MS4 & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Lateral Cutaneous Femoral Nerve Entrapment Syndrome, also known as Meralgia Paresthetica, results from entrapment of the lateral cutaneous femoral nerve, often as it exits the pelvis under the inguinal ligament.
Meralgia Paresthetica is associated with obesity, pregnancy, compression from clothing or belts and diabetes.
Symptoms include numbness, paresthesia and pain of the proximal lateral thigh. Signs or symptoms of radiculopathy such as weakness, loss of reflexes or severe back pain should not be present.
Diagnosis is clinical and does not require further imaging if there are no additional or concerning findings.
Meralgia Paresthetica typically resolves over time without intervention; however patients should be counseled on weight loss, diabetes control and avoidance of compressive clothing as relieving factors.
References
Solomons JNT, Sagir A, Yazdi C. Meralgia Paresthetica. Curr Pain Headache Rep. 2022;26(7):525-531. doi:10.1007/s11916-022-01053-7
Grossman MG, Ducey SA, Nadler SS, Levy AS. Meralgia paresthetica: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9(5):336-344. doi:10.5435/00124635-200109000-00007
Image from my.clevelandclinic.org
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
An EKG should be obtained quickly after a syncopal event to identify possible life-threatening causes such as ischemia and arrhythmia
WOBBLER is a good mnemonic for remembering additional EKG findings to look for in syncope
Wolff-Parkinson-White (WPW)
Check for delta wave on QRS
Obstructed AV node
Any potential heart blocks
Brugada syndrome
Na channel blockade that can cause ST elevations in anterior leads
Bifascicular block
Conduction blockade in two of the three fascicles increases risk of complete heart block
Left Ventricular Hypertrophy (LVH)
Can be a sign of HOCM (younger patients) or aortic stenosis (older patients)
Epsilon waves
Positive deflections after the QRS that is seen in arrhythmogenic right ventricular dysplasia
Repolarization abnormalities
Prolonged/shortened QT segments
References
Martow E, Sandhu R. When Is Syncope Arrhythmic? Med Clin North Am. 2019;103(5):793-807.
Solbiati M, Dipaola F, Villa P, et al. Predictive Accuracy of Electrocardiographic Monitoring of Patients With Syncope in the Emergency Department: The SyMoNE Multicenter Study. Acad Emerg Med. 2020;27(1):15-23.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Podcast 820: Who Qualifies for Take-Home Naloxone
11 Oct 2022
00:04:00
Contributor: Don Stader, MD
Educational Pearls:
Home naloxone is traditionally given to those at high risk for opioid overdose such as those in the ED due to an opioid overdose, opioid intoxication, or admit to illicit opioid use
There are a number of other patient populations that benefit from home naloxone including those on chronic opioid or benzodiazepine therapy, and those who report any type of illicit drug use
Any illicit drug could be laced with opioids, and those who use drugs are more likely to be present as bystanders when an opioid overdose occurs
Some important tips to remember when prescribing home naloxone
There is often a scannable QR code that instructs bystanders on how to recognize and intervene in an overdose
Inform the patient that naloxone is temporary and those who overdose are at high risk of overdosing again
Provide support and inform the patient that if they decide they would like to enter treatment/rehabilitation programs, they can return to the ED to start that process
References
Strang J, McDonald R, Campbell G, et al. Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine. Drugs. 2019;79(13):1395-1418.
Moustaqim-Barrette A, Dhillon D, Ng J, et al. Take-home naloxone programs for suspected opioid overdose in community settings: a scoping umbrella review. BMC Public Health. 2021;21(1):597.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Elevated lactate levels can be a useful indicator of critical illness in patients who meet SIRS criteria
Lactate can also be elevated due to other causes including seizures and medications such as albuterol and metformin
A recent study from Switzerland* performed routine point-of-care lactate testing in all elderly patients presenting at triage in the emergency department in order to determine the prevalence of elevated lactate in the population and its utility in predicting poor patient outcomes
Patients with seizure as their chief complaint were excluded from the study due to expected transient elevated lactate levels
Poor outcomes were defined as requiring extensive IVF and/orvasoactive medications, undergoing intubation, admission to the ICU, or death
27.1% of patients had an increased lactate but only 7.3% actually met poor outcome criteria
ED physicians should note that an increased lactate in an elderly patient does not mean that they are critically ill
Routine point-of-care lactate monitoring at triage is of limited usefulness and should instead be targeted towards those who meet critical illness criteria
*Errata: This study was performed in Switzerland, not Sweden as was stated in the podcast
References
Gosselin M, Mabire C, Pasquier M, et al. Prevalence and clinical significance of point of care elevated lactate at emergency admission in older patients: a prospective study. Intern Emerg Med. 2022;17(6):1803-1812.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
There are two major groups of local anesthetics: Amide and Esther
To recall what group an anesthetic belongs to, use this memory trick:
Amide has an 'i' in the name and Amide anesthetics have 2 'i's e.g., Lidocaine. Ester has no 'i' and most common Ester anesthetics have only one 'i' e.g., Tetracaine.
In a true allergy and/or contraindication to both local anesthetic groups, diphenhydramine is an acceptable alternative.
Epinephrine is administered with local anesthetics to decrease bleeding, increase duration of action, and minimize systemic spread of the anesthetic, thus reducing toxicity.
Symptoms of Local Anesthetic Systemic Toxicity (LAST) may begin with dizziness, confusion and/or slurred speech, and can progress to cardiovascular collapse and death.
Treat LAST with lipid emulsion therapy i.e. 'Intralipids' to create a lipid sink that absorbs anesthetic agent
Administer initial 1.5 ml/kg bolus (approximately 100 ml in 70 mg adult) followed by infusion rate of 0.25 mg/kg/hour. Do not surpass 10 mg/kg total.
References
Dickerson DM, Apfelbaum JL. Local anesthetic systemic toxicity. Aesthet Surg J. 2014;34(7):1111-1119. doi:10.1177/1090820X14543102
Bina B, Hersh EV, Hilario M, Alvarez K, McLaughlin B. True Allergy to Amide Local Anesthetics: A Review and Case Presentation. Anesth Prog. 2018;65(2):119-123. doi:10.2344/anpr-65-03-06
Macfarlane AJR, Gitman M, Bornstein KJ, El-Boghdadly K, Weinberg G. Updates in our understanding of local anaesthetic systemic toxicity: a narrative review. Anaesthesia. 2021;76 Suppl 1:27-39. doi:10.1111/anae.15282
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visithttps://emergencymedicalminute.com/edi-award/
Wide-complex tachycardia is defined as a heart rate > 100 BPM with a QRS width > 120 milliseconds
Wide-complex tachycardia of supraventricular origin is known as SVT with aberrancy
Aberrancy is due to bundle branch blocks
Mostly benign
Treated with adenosine or diltiazem
Wide-complex tachycardia of ventricular origin is also known as VTach
Originates from ventricular myocytes, which are poor inherent pacemakers
Dangerous rhythm that can lead to death
Treated with amiodarone or lidocaine
80% of wide-complex tachycardias are VTach
90% likelihood for patients with a history of coronary artery disease
In assessing a wide-complex tachycardia, it is best to treat it as a presumed ventricular tachycardia
Treating SVT with amiodarone or lidocaine does no harm
However, treating VTach with adenosine or diltiazem may worsen the condition
References
1. Littmann L, Olson EG, Gibbs MA. Initial evaluation and management of wide-complex tachycardia: A simplified and practical approach. Am J Emerg Med. 2019;37(7):1340-1345. doi:https://doi.org/10.1016/j.ajem.2019.04.027
2. Viskin S, Chorin E, Viskin D, Hochstadt A, Schwartz AL, Rosso R. Polymorphic Ventricular Tachycardia: Terminology, Mechanism, Diagnosis, and Emergency Therapy. Circulation. 2021;144(10):823-839. doi:10.1161/CIRCULATIONAHA.121.055783
3. Williams SE, O'Neill M, Kotadia ID. Supraventricular tachycardia: An overview of diagnosis and management. Clin Med J R Coll Physicians London. 2020;20(1):43-47. doi:10.7861/clinmed.cme.20.1.3
Summarized by Jorge Chalit, OMSIII | Edited by Meg Joyce & Jorge Chalit
Podcast 817: MI Risk during Elections
03 Oct 2022
00:02:23
Contributor: Aaron Lessen, MD
Educational Pearls:
2020 retrospective study with dat from two California hospitals compared rates of cardiovascular admissions in a five day period two weeks before and the five days after the presidential election
Hospitalization rate for acute cardiovascular disease increased by 17% and rate of acute myocardial infarction increased by 42%
Highest rates occurred in demographic of white males older than 75 years old
No significant difference between groups in rates of stroke and heart failure
References
Mefford MT, Rana JS, Reynolds K, et al. Association of the 2020 US Presidential Election With Hospitalizations for Acute Cardiovascular Conditions. JAMA Netw Open. 2022;5(4):e228031. Published 2022 Apr 1. doi:10.1001/jamanetworkopen.2022.8031
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
The management of severe asthma or COPD exacerbation is complex, especially when the patient requires intubation/ventilation
Asthma is an obstructive airway disease that can cause air trapping and hyperinflation of the lungs
To avoid worsening hyperinflation patients typically require slower respiratory rates, lower tidal volumes, and increased expiratory time when on a ventilator
Patients on a ventilator require very close monitoring to prevent worsening hyperinflation and associated complications including barotrauma and hypotension/cardiac arrest secondary to decreased venous return
If patient condition starts to worsen, decrease respiratory rate and tidal volume
In these cases, a decreased oxygen saturation is acceptable until their condition improves
If patient status continues to worsen, consider disconnecting the ventilator and pushing on the chest for approximately 30 seconds to help force out trapped air
If patient continues to decompensate, consider the possibility of a pneumothorax and determine if a chest tube is necessary
Remember to continue asthma/COPD management including albuterol/duonebs, steroids, magnesium, and alternatives including as heliox
References
Demoule A, Brochard L, Dres M, et al. How to ventilate obstructive and asthmatic patients. Intensive Care Med. 2020;46(12):2436-2449
Garner O, Ramey JS, Hanania NA. Management of Life-Threatening Asthma: Severe Asthma Series. Chest. 2022
Laher AE, Buchanan SK. Mechanically Ventilating the Severe Asthmatic. J Intensive Care Med. 2018;33(9):491-501
Summarized by Mark O'Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Podcast 815: Fluid Resuscitation in Pancreatitis
26 Sep 2022
00:03:21
Contributor: Aaron Lessen, MD
Educational Pearls:
Historically, pancreatitis has been treated with aggressive IV fluid rehydration. Recently published data shows this may not be appropriate.
A randomized, controlled, multi-hospital trial evaluated outcomes for patients with acute pancreatitis receiving lactated Ringer's solution
Aggressive fluid resuscitation group received 20ml/kg bolus + 3ml/hour
Moderate fluid resuscitation groups received either 10 ml/kg bolus if hypovolemic or no bolus if normovolemic. Both moderate resuscitation groups received 1.5ml/hr.
The primary outcome was development of moderately severe or severe pancreatitis. 22.1% of aggressive fluid resuscitation and 17.3% of moderate fluid resuscitation patients developed primary outcome.
The safety outcome was fluid overload. Fluid overload developed in 20.5% of aggressive resuscitation group and only 6.3% of moderate resuscitation group.
This trial was ended early due to differences in safety outcomes without obvious difference in primary outcome
Overall, aggressive fluid resuscitation had no benefit in treatment of acute pancreatitis and providers should be aware of fluid overload risk.
References
de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022;387(11):989-1000. doi:10.1056/NEJMoa2202884
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/
Podcast 814: Post-concussion Treatment
19 Sep 2022
00:02:50
Contributor: Aaron Lessen, MD
Educational Pearls:
Recent study looked at the impact of screen time on duration of post-concussive symptoms
125 patients aged 12-25 diagnosed with a concussion were randomized to either abstain from or have unrestricted screen time for 48 hours after injury
Patients with unrestricted screen time averaged approximately 5 hours/day of screen time
Patients in the no screen time group averaged approximately 1 hour/day of screen time
Statistically significant difference in duration of post-concussive symptoms
Unrestricted screen time cohort averaged 8 days of post-concussive symptoms
No screen time cohort averaged 3.5 days of post-concussive symptoms
ED physicians should encourage patients to limit screen time as much as possible in the first 48 hours after a concussion to promote faster recovery from post-concussive symptoms
References
Macnow T, Curran T, Tolliday C, et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2021;175(11):1124-1131.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
Most oxygen in the body is bound to hemoglobin, forming oxyhemoglobin. Less than 1% of the oxygen in the body is dissolved in plasma.
Pulse Oximeters (Pulse Ox) function by emitting wavelengths of light from one side, and capturing the amount absorbed on the opposite side. A calculation determined the amount of saturation.
Pulse Ox relies on pulsations in arterial flow to create a photoplethysmogram (pleth) for measurements
Patients with poor peripheral perfusion may have unreliable pulse ox.
Patient with an LVAD have constant flow and also unreliable pulse ox.
Pulse Ox is a useful tool when pacing to determine mechanical capture. If there is disparity between the electrical wave pulse and the rate on pulse ox, there is likely no mechanical capture leading to poor distal flow.
References
Eecen CMW, Kooter AJJ. Pulsoximeters: werking, valkuilen en praktische tips [Pulse oximetry: principles, limitations and practical applications]. Ned Tijdschr Geneeskd. 2021;165:D5891. Published 2021 May 11.
Elgendi M. On the analysis of fingertip photoplethysmogram signals. Curr Cardiol Rev. 2012;8(1):14-25. doi:10.2174/157340312801215782
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD
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.
PO medications are less frequently used in the ED due to their longer onset of action
The position the patient is in when given PO medications may affect how quickly the medication is absorbed
The quicker the medication passes through the stomach into the small intestine, the quicker it can be absorbed and metabolized
Recent study used in silico gastric biomechanics model to compare the length of time it took PO medications to pass through the stomach based on the patient's positioning
Compared the medication transit time in a stomach model placed in right lateral, left lateral, upright, and supine positions
Right lateral positioning resulted in the fastest time for medication to pass through the stomach and enter the duodenum
Likely due to the direction of gravity aligning with the antrum and pylorus of the stomach
Left lateral positioning had the slowest time for the pill to enter the small intestine
Likely due to gravity not aligning with stomach anatomy
The time to absorption in the right and left lateral position were significantly faster and slower respectively than that seen in the upright and supine positions
These results indicate that placing a patient in the right lateral position when giving PO medications may result in faster rate of medication onset than if the patient is in another position
References
Lee JH, Kuhar S, Seo JH, Pasricha PJ, Mittal R. Computational modeling of drug dissolution in the human stomach: Effects of posture and gastroparesis on drug bioavailability. Phys Fluids (1994). 2022;34(8):081904.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD
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.
Ketamine can be given at 0.2-0.3 mg/kg as subdissociative doses for pain control in the ED
Ketamine coadministered with Haldol may reduce agitation
A recent study in Iran compared subdissociative Ketamine given with 2.5 mg Haldol to 1 mg/kg Fentanyl for pain control in the ED
Ketamine with Haldol had better pain control than Fentanyl at 5, 10, 15 and 30 minutes
Ketamine with Haldol less frequently required rescue medication
Ketamine with Haldol did have increased agitation at only the 10 minute mark
Of note, there was not a Ketamine only group to compare
Ketamine with Haldol is a viable alternative combination for pain control
References
Moradi MM, Moradi MM, Safaie A, Baratloo A, Payandemehr P. Sub dissociative dose of ketamine with haloperidol versus fentanyl on pain reduction in patients with acute pain in the emergency department; a randomized clinical trial. Am J Emerg Med. 2022;54:165-171. doi:10.1016/j.ajem.2022.02.012
Sin B, Ternas T, Motov SM. The use of subdissociative-dose ketamine for acute pain in the emergency department. Acad Emerg Med. 2015;22(3):251-257. doi:10.1111/acem.12604
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
There is a 1-hour window for tooth replantation in ED
Cold milk is often best transport media unless there is access to specialized solutions (Hank's Balanced Solution)
Goal is to preserve periodontal ligament
Soaking in tap water should be avoided as it will lyse cells of periodontal ligament
If oral surgeon is rapidly available, have them perform replantation
Do not delay replantation to wait for an oral surgeon to become available
Steps in tooth reimplantation
Disturb the socket as little as possible
Handle tooth only by crown, don't touch root
Rinse tooth gently with tap water or saline, do not scrub it
Tooth should click back in place and remain stable
Don't manipulate after reimplantation
It may take weeks to determine if the tooth will survive
Studies have shown that replantation performed within one hour has a significantly better prognosis than those taking place after a greater amount of time has passed
Andreasen JO, Andreasen FM, Skeie A, Hjørting-Hansen E, Schwartz O. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article. Dent Traumatol. 2002;18(3):116-128.
De Brier N, O D, Borra V, Singletary EM, Zideman DA, De Buck E. Storage of an avulsed tooth prior to replantation: A systematic review and meta-analysis. Dent Traumatol. 2020;36(5):453-476.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
Achilles tendon rupture usually presents in younger, healthy patients after a sports injury
Patients typically present complaining of an abrupt onset ankle pain after feeling a "pop"
Pain can be localized to posterior ankle and patient's lack the ability to plantarflex
Achilles rupture is a clinical diagnosis and does not usually require imaging in the ED
Thompson test
Having patient lay on their stomach and squeezing the calf on the injured side should result in plantarflexion
If the Achilles is ruptured, no plantarflexion will occur
Treatment in the ED is to place the patient in a short leg posterior splint with some mild plantarflexion to aid in healing
After discharge patients should follow up with orthopedics
Recent study compared those who underwent the traditional open surgery, a minimally invasive surgery, and no surgery
No difference in functionality was noted between the groups 3 months to 1 year post injury
Those in the nonoperative group had slightly higher rates of repeat rupture (6%) than those in the surgical groups (<0.6% in each)
Patients undergoing minimally invasive surgery had the highest risk of nerve injury (5.2%), followed by traditional surgery (2.8%), and then nonoperative (0.6%)
References
Cuttica DJ, Hyer CF, Berlet GC. Intraoperative value of the thompson test. J Foot Ankle Surg. 2015;54(1):99-101.
Kauwe M. Acute Achilles Tendon Rupture: Clinical Evaluation, Conservative Management, and Early Active Rehabilitation. Clin Podiatr Med Surg. 2017;34(2):229-243.
Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or Surgical Treatment of Acute Achilles' Tendon Rupture. N Engl J Med. 2022;386(15):1409-1420.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD
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.
Positive End Expiratory Pressure (PEEP) is positive pressure within the lungs and maintained throughout the entire respiratory cycle. It is the pressure preventing alveoli from collapsing at the end of exhalation.
When using a bag valve mask (BVM) to ventilate patients, always attach the PEEP valve to prevent intrathoracic pressure from returning to atmospheric pressure which would allow alveoli collapse.
A BVM with a good seal to patients face and with an attached PEEP valve provides the same support as BiPAP or CPAP.
A generally acceptable PEEP setting is 5 cmH2O.
References
Mora Carpio AL, Mora JI. Positive End-Expiratory Pressure. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 27, 2021.
Harrison MJ. PEEP and CPAP. Br Med J (Clin Res Ed). 1986;292(6521):643-644. doi:10.1136/bmj.292.6521.643
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
A gentleman came in from a nursing home with symptoms concerning for sepsis. He was hypotensive, hypoxic, febrile, and mentally altered.
His past medical history included previous strokes which had left him with deficits for which he required a feeding tube.
Initial workup included some point of care labs which revealed a sodium of 165 mEq/L (normal range 135-145)
Hypernatremia
What causes it?
Dehydration, from insufficient fluid intake. This might happen in individuals who cannot drink water independently, such as infants, elderly, or disabled people, as was the case for this patient.
Other causes of dehydration/hypernatremia include excessive sweating; diabetes insipidus; diuretic use; kidney dysfunction; and severe burns which can lead to fluid loss through the damaged skin.
How do you correct it?
Need to correct slowly, not more than 10 to 12 meq/L in 24 hours
Can do normal saline (0.9%) or half saline (0.45%) and D5, at 150-200 mL per hour.
Check the sodium frequently (every 2-3 hours)
Will likely need ICU-level monitoring
What happens if you correct it too quickly?
Cerebral edema
Seizures
Bonus fact: Correction of hyponatremia too quickly causes osmotic demyelination syndrome (ODS).
References
Chauhan, K., Pattharanitima, P., Patel, N., Duffy, A., Saha, A., Chaudhary, K., Debnath, N., Van Vleck, T., Chan, L., Nadkarni, G. N., & Coca, S. G. (2019). Rate of Correction of Hypernatremia and Health Outcomes in Critically Ill Patients. Clinical journal of the American Society of Nephrology : CJASN, 14(5), 656–663. https://doi.org/10.2215/CJN.10640918
Lindner, G., & Funk, G. C. (2013). Hypernatremia in critically ill patients. Journal of critical care, 28(2), 216.e11–216.e2.16E20. https://doi.org/10.1016/j.jcrc.2012.05.001
Muhsin, S. A., & Mount, D. B. (2016). Diagnosis and treatment of hypernatremia. Best practice & research. Clinical endocrinology & metabolism, 30(2), 189–203. https://doi.org/10.1016/j.beem.2016.02.014
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSIII
Podcast 807: Ring Removal Tricks
23 Aug 2022
00:04:11
Contributor: Jared Scott, MD
Educational Pearls:
If a patient is in significant pain, a digital block can be helpful. Pain management alone may allow for manual ring removal.
Ring cutters and trauma shears with specialized ring cutters can be attempted but will destroy the ring and some materials may be resistant to cutting.
2 alternative options are presented which aim to reduce edema above the ring to assist removal:
Move the ring as proximally as possible. Wrap large size suture from the ring distally beyond PIP joint. Slide the ring over the suture and off the finger.
Wrap a tourniquet from distal to proximal including over the ring. Have the patient hold the tourniquet in place while they elevate their hand above the head for 15 minutes. Take down the tourniquet then remove the ring.
References
Asher CM, Fleet M, Bystrzonowski N. Ring removal: an illustrated summary of the literature. Eur J Emerg Med. 2020;27(4):268-273. doi:10.1097/MEJ.0000000000000658
Walter J, DeBoer M, Koops J, Hamel LL, Rupp PE, Westgard BC. Quick cuts: A comparative study of two tools for ring tourniquet removal. Am J Emerg Med. 2021;46:238-240. doi:10.1016/j.ajem.2020.07.039
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
Physicians are typically advised not to trust computer interpretation of ECGs
Retrospective study was done of computer interpreted normal ECGs to evaluate the accuracy of such an interpretation
989 ECGs were interpreted as "Normal sinus rhythm, Normal ECG" by proprietary cardiology software on MUSE Cardiology Information System
These EKGs received follow up interpretation by cardiologists which was considered the "gold standard" for interpretation
18.6% of "normal ECG" had at least one abnormality identified by the cardiologist
6.1% of these discrepant interpretations were deemed potentially clinically significant
Only 1% were classified as possible ischemia
On retrospective chart review:
Six patients underwent non-emergent cardiac catheterization
Two had cardiac interventions
One had three PCI stents to a prior CABG graft
One had a scheduled outpatient cardiac catheterization but was admitted and ended up receiving a CABG graft
Study showed that discrepancies between computer interpretation of "Normal ECG" and cardiologist re-interpretation were not clinically significant
Emergency physicians should still screen ECGs per AHA guidelines
References
Winters LJ, Dhillon RK, Pannu GK, Terrassa P, Holmes JF, Bing ML. Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. Am J Emerg Med. 2022;51:384-387.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD
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.
Patients with recurrent ascites may need frequent outpatient or emergency department paracentesis which can be time consuming and uncomfortable for patients.
Tunneled peritoneal catheters are a permanent alternative therapy which allows fluid drainage at home by patient or caregiver.
There has been theoretical concern that long term placement of tunneled peritoneal catheters may increase risk of infection, thus they are more commonly placed as a palliative measure for patients with end stage cancer and malignant ascites with shorter anticipated life spans.
However, a recent small study found that in both patients with malignant ascites and recurrent ascites from cirrhosis, tunneled peritoneal catheter placement reduced symptoms from ascites and did not increase risk of infection or leakage at catheter site, or spontaneous bacterial peritonitis after four weeks. More research is emerging and tunneled peritoneal catheters may become more common.
References
Kimer N, Riedel AN, Hobolth L, et al. Tunneled Peritoneal Catheter for Refractory Ascites in Cirrhosis: A Randomized Case-Series. Medicina (Kaunas). 2020;56(11):565. Published 2020 Oct 27. doi:10.3390/medicina56110565
Petzold G, Bremer SCB, Heuschert FC, et al. Tunnelled Peritoneal Catheter for Malignant Ascites-An Open-Label, Prospective, Observational Trial. Cancers (Basel). 2021;13(12):2926. Published 2021 Jun 11. doi:10.3390/cancers13122926
Corrigan M, Thomas R, McDonagh J, et al. Tunnelled peritoneal drainage catheter placement for the palliative management of refractory ascites in patients with liver cirrhosis. Frontline Gastroenterol. 2020;12(2):108-112. Published 2020 Feb 28. doi:10.1136/flgastro-2019-101332
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
Tachycardia describes a heart rate of >120 beats per minute
Wide Complex describes a QRS duration of >120 ms or 3 small boxes on a standard EKG
The major differential for a wide complex tachycardia is Ventricular Tachycardia (VT), aka "V Tach", or Supraventricular Tachycardia (SVT) with Aberrancy
SVT alone is a narrow complex tachycardia, but as rate increases a right or left bundle branch block pattern may emerge, creating SVT with Aberrancy seen as a wide complex on EKG
It is important to distinguish the rhythms as treatment for stable VT differs from treatment(s) for stable SVT
Brugada Criteria is an algorithm for determining if wide complex tachycardia is VT with a high degree of sensitivity and specificity.
Following is a simple ED approach based on brugada criteria to determine VT on EKG. If either condition is true, suspect and treat VT:
Concordance: All precordial leads have QRS complexes that are either all positive or all negative.
R-S interval: >100 ms in any one precordial lead.
Also note that VT is more common in patients who are elderly and/or have cardiac comorbidities of ischemic or structural heart disease
References
Reithmann C. Tachykardien mit breiten QRS-Komplexen [Differential diagnosis of wide QRS complex tachycardia]. MMW Fortschr Med. 2019;161(13):48-56. doi:10.1007/s15006-019-0022-x
Ding WY, Mahida S. Wide complex tachycardia: differentiating ventricular tachycardia from supraventricular tachycardia. Heart. 2021;107(24):1995-2003. doi:10.1136/heartjnl-2020-316874
Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83(5):1649-1659. doi:10.1161/01.cir.83.5.1649
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
Awareness with recall of paralysis can occur in intubated and ventilated patients receiving paralytic medications
Patients who suffer from this effect are at high risk of developing severe PTSD, depression, and suicidal ideations
Occurs in approximately 0.1-0.2% of patients undergoing general anesthesia in an OR setting
2021 study showed patients intubated in the ED have a much higher rate of experiencing awareness during intubation
2.6% chance of awareness in patients undergoing intubation and mechanical ventilation in the ED
Higher rates with rocuronium likely due to its longer duration of action
New follow up study from 2022 showed 3.4% of patients aware when paralyzed for mechanical ventilation in ED
5.5% of patients receiving rocuronium had awareness occur
Patients who received other paralytics had a <1% rate of awareness during intubation
Important to be proactive with sedation and pain medications to decrease risk of awareness with recall of paralysis, especially in patients receiving rocuronium
References
Fuller BM, Pappal RD, Mohr NM, et al. Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study. Crit Care Med. 2022.
Leslie K, Davidson AJ. Awareness during anesthesia: a problem without solutions? Minerva Anestesiol. 2010;76(8):624-628.
Pappal RD, Roberts BW, Mohr NM, et al. The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med. 2021;77(5):532-544.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
Selected audio from our event, Palliative, hosted on June 27, 2022 in conjunction with Children's Hospital Colorado's Department of Palliative Medicine and The Denver Hospice's Footprints Program.
Keynote address by Dr. Nadia Tremonti, pediatric palliative care physician at Children's Hospital of Michigan
Expert Panel composed of Dr. Kimberly Bennett, medical director for TDH's Footprints Program, Dora Mueller, clinical nurse coordinator for palliative care at Children's and Cassie Matz, LCSW bereavement coordinator at Children's.
The evening commenced following a screening of the 2019 award-winning documentary, Palliative, featuring Dr. Nadia Tremonti's work at Children's Hospital of Michigan. You can watch the documentary for free at Kanopy.com using your library card using the following link: https://www.kanopy.com/product/palliative
Podcast 802: Intranasal Medication Administration for Pediatric Patients
02 Aug 2022
00:03:24
Contributor: Aaron Lessen, MD
Educational Pearls:
Intranasal medication administration is a convenient, quick, and relatively painless option for pediatric patients
Often used as an initial medication to help control pain in children prior to establishing an IV
Using an atomizer is preferred when administering intranasal medications
The syringe should be angled towards the ipsilateral eye or occiput rather than straight upwards
Do not administer more than 1 mL of fluid per nostril as volumes greater than 1 mL are not sufficiently absorbed
Intranasal medication doses differ from the traditional IV dosages and have a slower onset of action
References
Del Pizzo J, Callahan JM. Intranasal medications in pediatric emergency medicine. Pediatr Emerg Care. 2014;30(7):496-501; quiz 502-494.
Fantacci C, Fabrizio GC, Ferrara P, Franceschi F, Chiaretti A. Intranasal drug administration for procedural sedation in children admitted to pediatric Emergency Room. Eur Rev Med Pharmacol Sci. 2018;22(1):217-222.
Rech MA, Barbas B, Chaney W, Greenhalgh E, Turck C. When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications. Ann Emerg Med. 2017;70(2):203-211.
Schoolman-Anderson K, Lane RD, Schunk JE, Mecham N, Thomas R, Adelgais K. Pediatric emergency department triage-based pain guideline utilizing intranasal fentanyl: Effect of implementation. Am J Emerg Med. 2018;36(9):1603-1607.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
Mental Health Monthly #14: Substance-Induced Psychosis (Part II)
27 Jul 2022
00:24:05
In this second episode of a two-part mini-series, we feature Dr. Nadia Haddad, a Colorado psychiatrist, and Dr. Ricky Dhaliwal, an emergency medicine physician, as they discuss the various treatment modalities for substance-induced psychosis. They explore pharmacologic treatments, inpatient and outpatient treatments, and ways that emergency providers can improve their care for psychiatric patients with comorbid medical conditions. Lastly, they consider the different causes for repeat visits from mentally ill patients.
Key Points:
Pharmacologic treatments for substance-induced psychosis are similar to those for other types of psychosis; these include medications like Zyprexa, Haldol, and, as a third-line treatment, IM Thorazine.
Droperidol is used more commonly in the emergency setting, compared with the psychiatric setting.
Given the risk for respiratory depression from Zyprexa combined with benzodiazepines, psychiatrists may choose to use Thorazine or Haldol/Ativan/Benadryl instead.
It is important to reassess patients after substances wear off to determine whether they meet criteria for admission to inpatient psychiatry, though psychiatric assessments are limited by geographic constraints.
The admitting psychiatry team will reassess the patient to differentiate substance-induced psychosis vs other psychoses; often this includes obtaining collateral.
Helpful notes from the ED include: medications administered or restraints placed (can help extrapolate a patient's level of agitation), vital signs, prior records.
Some people will be more open about suicidality while intoxicated and less open about it while sober so it is important to obtain additional information for corroboration.
On average, patients stay in the detox unit for 3-4 days, though some may stay longer for protracted substance-induced psychosis if they have a long-standing history of daily substance use.
It is important to discharge patients with quick follow-up and potential placement into the various mental health programs including partial hospitalization, residential, or outpatient programs.
Emergency rooms can improve by taking psychiatric patients seriously, especially when they are transferred to the hospital from a psychiatric facility for medical management.
Repeat visits stem partially from the ambivalence that accompanies substance use disorders, including patients' difficulty in giving up the substance due the purpose it may serve in their lives.
Many substance use disorder programs are siloed from the medical system, which pose a challenge to interdisciplinary communication.
Podcast 801: Push Dose Vasopressors
26 Jul 2022
00:03:10
Contributor: Aaron Lessen, MD
Educational Pearls:
There are two common options for push-dose vasopressor: phenylephrine and epinephrine. Both have been studied in the setting of the OR, but are lacking data in emergency room utilization.
A recent retrospective study at one hospital compared the two options for effectiveness and safety. The data showed phenylephrine raised systolic pressure an average 26 points while epinephrine raised the systolic pressure higher, an average of 33 points.
Additionally, the same study showed dosing errors were more common in epinephrine. The error rates were 13% and 2% when using premixed syringes of epinephrine and phenylephrine respectively. However, overall no increase in adverse outcomes were reported between the two drugs in this study.
References
Nam E, Fitter S, Moussavi K. Comparison of push-dose phenylephrine and epinephrine in the emergency department. Am J Emerg Med. 2022;52:43-49. doi:10.1016/j.ajem.2021.11.033
Weingart S. Push-dose pressors for immediate blood pressure control. Clin Exp Emerg Med. 2015;2(2):131-132. Published 2015 Jun 30. doi:10.15441/ceem.15.010
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
A recent study evaluated the association between the degree of fever and mortality rate in patients presenting to a set of Emergency Departments in Israel
Febrile patients with a temperature > 38.0 C were recorded and these patients were compared against local death records to determine the all-cause 30-day mortality rate
8.1% of patients evaluated in the ED were determined to be febrile
30-day mortality for all febrile patients was around 12%
Patients with fever >40 C have a mortality rate approaching 24%
Patients febrile to >40 C had increased mortality, ICU admissions, and AKIs compared to those with lesser degrees of fever
Those with a body temperature of between 39.2-39.5 C had the lowest mortality rates which may indicate the protective role of fever and warrants further research
References
Marcusohn E, Gibory I, Miller A, Lipsky AM, Neuberger A, Epstein D. The association between the degree of fever as measured in the emergency department and clinical outcomes of hospitalized adult patients. Am J Emerg Med. 2022;52:92-98.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
Oseltamivir (Tamiflu) is an antiviral medication used commonly to treat influenza
Trials show that the medication reduces the duration of illness by less than 1 day (~16 hours in one systematic review)
Benefit only occurs if taken within 48 hours of symptom onset
Must be taken for 5 days
A 2024 meta-analysis reviewed 15 randomized-controlled trials for the risk of hospitalization
No reduction in hospitalizations with oseltamivir in patients over the age of 12
No difference in high-risk patients over the age of 65 or those with comorbidities
The authors note that the confidence interval in these populations is wide, indicating a need for subsequent studies in high-risk populations
Oseltamivir is associated with adverse effects including nausea, vomiting, and neurologic symptoms
The risk of adverse effects may outweigh the benefits of a small reduction in the duration of illness
References
1. Hanula R, Bortolussi-Courval É, Mendel A, Ward BJ, Lee TC, McDonald EG. Evaluation of Oseltamivir Used to Prevent Hospitalization in Outpatients with Influenza: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2024;184(1):18-27. doi:10.1001/jamainternmed.2023.0699
2. Jefferson T, Jones M, Doshi P, Spencer EA, Onakpoya I, Heneghan CJ. Oseltamivir for influenza in adults and children: Systematic review of clinical study reports and summary of regulatory comments. BMJ. 2014;348(April):1-18. doi:10.1136/bmj.g2545
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit
Podcast 799: EKG Abnormalities in Renal Failure
19 Jul 2022
00:04:00
Contributor: Peter Bakes, MD
Educational Pearls:
Patients in renal failure may have elevated serum potassium levels which can result in EKG changes.
EKG changes in the setting of hyperkalemia generally depend on the serum level. Mild elevation may cause peaked T waves. At higher serum levels there will be loss of P waves plus wide complex tachycardia. There can be progression to fatal arrhythmias.
Treatment of acute hyperkalemia involves multiple mechanisms. Calcium gluconate stabilizes the cardiac membrane (of note, its duration of action is 1 hour). Insulin with Glucose and Bicarbonate both act to shift extracellular potassium into cells. Enhanced elimination of potassium is accomplished via Kayexalate or Lokelma. Definitive treatment for hyperkalemia is hemodialysis.
The differential for wide complex non-tachycardic rhythm on EKG includes: left ventricular hypertrophy, left bundle branch block, pacemaker, electrolyte abnormalities including hyperkalemia.
References
Palmer BF, Clegg DJ. Diagnosis and treatment of hyperkalemia. Cleve Clin J Med. 2017;84(12):934-942. doi:10.3949/ccjm.84a.17056
Watanabe R. Hyperkalemia in chronic kidney disease. Rev Assoc Med Bras (1992). 2020;66Suppl 1(Suppl 1):s31-s36. Published 2020 Jan 13. doi:10.1590/1806-9282.66.S1.31
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
Prior, smaller studies showed intravenous Vitamin C given to patients with sepsis significantly improved patient mortality and additional outcomes.
A recently published, randomized control trial with >800 ICU patients who received up to 4 days of IV Vit C or placebo concluded that the end points of death or persistent organ dysfunction at 28 days were unaffected by Vitamin C administration. There were no adverse safety outcomes associated with Vitamin C administration.
Based on this trial, it is unlikely that Vitamin C will become a mainstay of treatment for sepsis patients.
References
Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229-1238. doi:10.1016/j.chest.2016.11.036
Lamontagne F, Masse MH, Menard J, et al. Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit. N Engl J Med. 2022;386(25):2387-2398. doi:10.1056/NEJMoa2200644
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
Septic shock management has traditionally endorsed rapid fluid resuscitation and the administration of vasopressors
Current guidelines are for patients to initially receive a 30 ml/kg fluid bolus then additional fluid as needed for continued hypotension
The ideal volume of fluid needed to maximize patient outcomes has been debated
A recent ICU-based study examined mortality differences between patient receiving restricted vs standard fluid therapy for septic shock
There was no significant difference in the rate of mortality or adverse outcomes between the two groups indicating that the amount of fluid used after the initial bolus does not affect patient outcomes
More research needed to evaluate the ideal fluid volumes used in the initial resuscitation of septic shock
Errata: *** "The primary outcome was death within 90 days after randomization"
References
Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247.
Meyhoff TS, Møller MH, Hjortrup PB, Cronhjort M, Perner A, Wetterslev J. Lower vs higher fluid volumes during initial management of sepsis: a systematic review with meta-analysis and trial sequential analysis. Chest. 2020;157(6):1478-1496.
Meyhoff TS, Hjortrup PB, Wetterslev J, et al. Restriction of Intravenous Fluid in ICU Patients with Septic Shock. N Engl J Med. 2022;386(26):2459-2470.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
McKnight RF, Adida M, Budge K, Stockton S, Goodwin GM, Geddes JR. Lithium toxicity profile: a systematic review and meta-analysis. Lancet. 2012;379(9817):721-728.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
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.
Podcast 793: Postintubation Sedation and Analgesia
27 Jun 2022
00:06:17
Contributor: Peter Bakes, MD
Educational Pearls:
When intubating a patient, it is important to consider what medications will be used for post-intubation sedation and analgesia
The common non-benzodiazepine sedating medications are propofol, precedex, and ketamine
Propofol is frequently used in the emergency department, and it lowers ICP and MAP making it the preferred sedative for patients with intracranial bleeds
Precedex is a milder sedative used in the ICU because it decreases time to extubation and reduces the risk of complications associated with long term intubation
Ketamine should be used in hypotensive patients because it does not lower blood pressure, and its bronchodilatory effect is beneficial for asthmatic patients
Versed and ativan are the most commonly encountered benzodiazepine sedatives, but they are infrequently used because they increase the risk of delirium and delay extubation
Benzodiazepines are useful for sedation in patients with delirium tremens
For post intubation analgesia, fentanyl is the drug of choice since it has a lower risk of hypotension than is seen in other narcotics
In the emergency department, intubated and sedated patients should initially be sedated to a RASS of -2 while obtaining imaging, but aim for a RASS of -1 after to decrease side effects and promote earlier extubation
References
Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289(22):2983-2991.
Garner O, Ramey JS, Hanania NA. Management of Life-Threatening Asthma: Severe Asthma Series. Chest. 2022.
Keating GM. Dexmedetomidine: A Review of Its Use for Sedation in the Intensive Care Setting. Drugs. 2015;75(10):1119-1130.
McKeage K, Perry CM. Propofol: a review of its use in intensive care sedation of adults. CNS Drugs. 2003;17(4):235-272.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD
Emergency Medical Minute's Palliative screening event is tonight! There is still time to buy tickets to this intimate evening diving into the nuance of pediatric palliative care, purchase tickets on eventbrite!
Podcast 792: Rectal Prolapse
21 Jun 2022
00:04:45
Contributor: Jarod Scott, MD
Educational Pearls:
Rectal prolapse is an evagination of the rectal tissue through the anal opening
Factors that weaken the pelvic floor muscles increase the risk of rectal prolapse
These include age > 40, female, multiple pregnancies, constipation, diarrhea, cystic fibrosis, prior pelvic floor surgeries, or other pelvic floor abnormalities
Noninvasive treatment options include increasing fluid and fiber intake to soften stools as well as using padding/taping to reinforce the perineum
Surgery is an option to repair the prolapse so long as the patient is a good surgical candidate
Medical sugar can be used as a desiccant to dry out and shrink the prolapse thus allowing for easier manual replacement
References
Coburn WM, 3rd, Russell MA, Hofstetter WL. Sucrose as an aid to manual reduction of incarcerated rectal prolapse. Ann Emerg Med. 1997;30(3):347-349.
2Gachabayov M, Bendl R, Flusberg M, et al. Rectal prolapse and pelvic descent. Curr Probl Surg. 2021;58(9):100952.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD
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.
Hyperglycemic Hyperosmolar State (HHS) is less common than Diabetic Ketoacidosis (DKA) but is associated with a mortality rate up to 10 times greater than that seen in DKA
Typically seen in elderly patients with severely elevated blood glucose levels (>1000 mg/dL) and an increased plasma osmolality
Unlike in DKA, patients with HHS do not have elevated ketones
Treatment of HHS includes insulin administration along with correcting fluid and electrolyte abnormalities
When treating HHS, it is important to monitor and follow osmolality regularly because over-rapid correction can result in the development of cerebral edema
References
Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017;101(3):587-606.
Long B, Willis GC, Lentz S, Koyfman A, Gottlieb M. Diagnosis and Management of the Critically Ill Adult Patient with Hyperglycemic Hyperosmolar State. J Emerg Med. 2021;61(4):365-375.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD
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.
On the Streets #14: Trauma Activations in the Field
15 Jun 2022
00:18:03
The Emergency Medical Minute is excited to announce that we our upcoming event, Palliative. Check out our event page for more information and to buy tickets: Palliative Eventbrite Page
Podcast 790: Opioids vs OTC Pain Meds
14 Jun 2022
00:03:04
Contributor: Aaron Lessen, MD
Educational Pearls:
NSAIDs are a potential alternative to opioids for pain management and are associated with decreased rates of adverse effects
A recent study evaluated the effectiveness of ibuprofen and oxycodone for pain management in pediatric patients with isolated, acute-limb fractures
Participants were discharged home with either ibuprofen or oxycodone and followed for six weeks
There was no difference in pain scores between those taking ibuprofen and those taking oxycodone indicating that they had comparable analgesic effects
Those in the ibuprofen group experienced significantly less adverse events compared to those taking oxycodone
The participants in the ibuprofen group showed quicker return to their normal activities and improved quality of life
In pediatric patients with fracture-related pain, ibuprofen is a safer alternative to oxycodone that is equally effective for pain control
References
Ali S, Manaloor R, Johnson DW, et al. An observational cohort study comparing ibuprofen and oxycodone in children with fractures. PLoS One. 2021;16(9):e0257021.
Cooney MF. Pain Management in Children: NSAID Use in the Perioperative and Emergency Department Settings. Paediatr Drugs. 2021;23(4):361-372.
Yin X, Wang X, He C. Comparative efficacy of therapeutics for traumatic musculoskeletal pain in the emergency setting: A network meta-analysis. Am J Emerg Med. 2021;46:424-429.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD
The Emergency Medical Minute is excited to announce that we our upcoming event, Palliative. Check out our event page for more information and to buy tickets: Palliative Eventbrite Page
Direct Oral Anticoagulants (DOACs) have surpassed Warfarin and Lovenox® for anticoagulation as they do not require injection and allow for easier discharge. In the ED, they are commonly prescribed after PE or DVT diagnosis.
Common DOACs are Apixaban (Eliquis®) and Rivaroxaban (Xarelto®). There has not been a direct head to head study comparing outcomes.
2 large observational studies evaluated the recurrence of clots and bleeding risk in patients with newly prescribed Eliquis® or Xarelto® for DVT or PE. Both studies found that Eliquis® had superior outcomes.
Further data is required to determine the preferred DOAC. A randomized trial comparing the two DOACs is upcoming with enrollment ending in 2023.
References
Dawwas GK, Leonard CE, Lewis JD, Cuker A. Risk for Recurrent Venous Thromboembolism and Bleeding With Apixaban Compared With Rivaroxaban: An Analysis of Real-World Data. Ann Intern Med. 2022;175(1):20-28. doi:10.7326/M21-0717
Aryal MR, Gosain R, Donato A, et al. Systematic review and meta-analysis of the efficacy and safety of apixaban compared to rivaroxaban in acute VTE in the real world. Blood Adv. 2019;3(15):2381-2387. doi:10.1182/bloodadvances.2019000572
Image from:
Bristol-Myers Squibb Company. Eliquis 10 Million Patients and Counting. Sec.gov. https://www.sec.gov/Archives/edgar/data/14272/000114036119003478/s002621x16_425.htm. Accessed June 12, 2022.
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD
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.
Epinephrine is essential in the treatment of anaphylaxis, but is epinephrine dangerous from a cardiovascular perspective?
A 2024 study in the Journal of the American College of Emergency Physicians Open sought to answer this question.
Methods:
Retrospective observational study at a Tennessee quaternary care academic ED that analyzed ED visits from 2017 to 2021 involving anaphylaxis treated with IM epinephrine.
The primary outcome was cardiotoxicity
Results:
Out of 338 patients, 16 (4.7%) experienced cardiotoxicity. Events included ischemic EKG changes (2.4%), elevated troponin (1.8%), atrial arrhythmias (1.5%), ventricular arrhythmia (0.3%), and depressed ejection fraction (0.3%).
Affected patients were older, had more comorbidities, and often received multiple epinephrine doses.
Bottom line:
All adults presenting with anaphylaxis should be rapidly treated with epinephrine but monitored closely for cardiotoxicity, especially in patients with a history of hypertension and those who receive multiple doses.
These results are supported by a 2017 study that found that 9% (4/44) of older patients who received epinephrine for anaphylaxis had cardiovascular complications.
References
Kawano, T., Scheuermeyer, F. X., Stenstrom, R., Rowe, B. H., Grafstein, E., & Grunau, B. (2017). Epinephrine use in older patients with anaphylaxis: Clinical outcomes and cardiovascular complications. Resuscitation, 112, 53–58. https://doi.org/10.1016/j.resuscitation.2016.12.020
Pauw, E. K., Stubblefield, W. B., Wrenn, J. O., Brown, S. K., Cosse, M. S., Curry, Z. S., Darcy, T. P., James, T. E., Koetter, P. E., Nicholson, C. E., Parisi, F. N., Shepherd, L. G., Soppet, S. L., Stocker, M. D., Walston, B. M., Self, W. H., Han, J. H., & Ward, M. J. (2024). Frequency of cardiotoxicity following intramuscular administration of epinephrine in emergency department patients with anaphylaxis. Journal of the American College of Emergency Physicians open, 5(1), e13095. https://doi.org/10.1002/emp2.13095
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit OMS II
Mental Health Monthly #13: Substance-Induced Psychosis (Part I)
08 Jun 2022
00:16:16
Substance-Induced Psychosis (Part I)
In this first episode of a two-part mini-series, we feature Dr. Nadia Haddad, a Colorado psychiatrist, and Dr. Ricky Dhaliwal, an emergency medicine physician, as they discuss the different substances that cause psychosis and their unique presentations in the ED and in the psychiatric world. First, Dr. Haddad establishes a medical definition of psychosis. Then, Dr. Haddad and Dr. Dhaliwal partake in a fruitful discussion, each providing their unique perspective on the drugs that affect our patient populations today.
Key Points:
Psychosis is a cognitive processing disorder, which leads to auditory hallucinations, visual hallucinations, and delusions.
Axis one psychosis like that from schizophrenia or mania typically produces auditory hallucinations, not visual hallucinations. Delusions are also common in underlying psychiatric psychosis.
One of the most common substances that cause psychosis today is methamphetamine. Meth-induced psychosis can mimic schizophrenia symptoms, though tactile hallucinations are very common with methamphetamine use.
Methamphetamine is active for up to about 8 hours but can vary depending on underlying mental health predispositions, which can be exacerbated for several days or a week before neurotransmitters right themselves after meth use.
Cannabis can lead to psychosis and paranoia for people - especially young people - with a predisposition to schizophrenia or bipolar.
Alcohol-related psychosis comes primarily from withdrawal, though acute alcohol intoxication may cause mild alcoholic hallucinosis.
The hallmark of delirium tremens is a fluctuating, waxing-and-waning consciousness, which can occur 72 hours after the last drink. DTs can occur after treatment of the physical withdrawal symptoms.
Alcohol withdrawal can occur even at high BALs relative to a patient's baseline.
Cocaine psychosis is similar to methamphetamine-induced psychosis.
Recorded, Summarized, and Edited By: Jorge Chalit
Podcast 788: Tracheostomy Bleeding
07 Jun 2022
00:05:00
Contributor: Aaron Lessen, MD
Educational Pearls:
Tracheostomy bleeding is a rare but potentially life-threatening complication that usually occurs within the first month of tracheostomy tube placement
No matter how severe the bleeding, every patient should be evaluated to rule out a tracheo-innominate fistula between the tracheostomy and the innominate artery
If the patient is currently bleeding and has a cuffed tracheostomy tube, over-inflate the balloon to compress the bleeding vessel
Consider replacing an uncuffed tracheostomy tube with a cuffed tube or an ET tube
If the tracheostomy was performed in the last seven days, use a bougie or bronchoscope to replace the uncuffed tube due to increased risk of opening a false track into the subcutaneous tissue
If bleeding cannot be controlled, follow mass-transfusion protocols, and as a last resort, remove the tube and insert a finger into the stoma to manually compress the artery
References
Bontempo LJ, Manning SL. Tracheostomy Emergencies. Emerg Med Clin North Am. 2019;37(1):109-119.
Khanafer A, Hellstern V, Meißner H, et al. Tracheoinnominate fistula: acute bleeding and hypovolemic shock due to a trachea-innominate artery fistula after long-term tracheostomy, treated with a stent-graft. CVIR Endovasc. 2021;4(1):30.
Manning Sara, Bontempo Laura. Complications of Tracheostomies. In: Mattu A and Swadron S, ed. ComPendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/reckOdDn9Ljn7sBLy/Complications-of-Tracheostomies. Updated August 17, 2021. Accessed June 5, 2022.
Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, MPH & Erik Verzemnieks, MD
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.
Transcatheter aortic valve replacement (TAVR) is an increasingly common endovascular procedure to treat aortic stenosis
TAVR is an alternative to the open approach surgical aortic valve replacement (SAVR) for patients who are inoperable or are high risk surgical candidates
Following TAVR, there is increased risk of stroke, particularly in the first 30 days
TAVR-related strokes are due to embolic debris left on the valve root, which is generally cleaned out during SAVR
Further, following the procedure many patients are anticoagulated which increases the risk for conversion to hemorrhagic stroke
Isolated, unexplained nausea and vomiting in elderly patients should prompt concern for a neurologic workup with imaging - even more so if they have recently undergone TAVR
References
Davlouros PA, Mplani VC, Koniari I, Tsigkas G, Hahalis G. Transcatheter aortic valve replacement and stroke: a comprehensive review. J Geriatr Cardiol. 2018;15(1):95-104. doi:10.11909/j.issn.1671-5411.2018.01.008
Gleason TG, Reardon MJ, Popma JJ, et al. 5-Year Outcomes of Self-Expanding Transcatheter Versus Surgical Aortic Valve Replacement in High-Risk Patients. J Am Coll Cardiol. 2018;72(22):2687-2696. doi:10.1016/j.jacc.2018.08.2146
Siontis GCM, Overtchouk P, Cahill TJ, et al. Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of symptomatic severe aortic stenosis: an updated meta-analysis. Eur Heart J. 2019;40(38):3143-3153. doi:10.1093/eurheartj/ehz275
Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD
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.