Emergency Medical Minute

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...

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; Sur...

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 bett...

Contributor: Nick Tsipis, MD Educational Pearls: Acute hyperkalemia is characterized as serum K of 5.4 or higher in non-hemolyzed samples Hyperkalemia is commonly associated with end stage renal disease, acute kidney injury or acute renal failure Cardiac dysrhythmias are the primary concern with hyperkalemia, common EKG changes (and approximate serum levels) can include: Peaked T waves that start...

Dr. Kim Nordstrom, a practicing emergency psychiatrist and associate professor with the University of Colorado, discusses various work-up models alongside valuable bedside tools for elderly patients with acute psychosis. In this podcast, she explores the methods to differentiate primary psychiatric psychosis from medically mediated psychosis in the elderly using an empirical bedside tool. Furtherm...

Contributor: Nick Tsipis, MD Educational Pearls: Observational study in Israel evaluated cohort of vaccinated pregnant women receiving the initial Pfizer-BioNTech COVID-19 mRNA vaccine  Looked at 24,288 newborns with about 16,697 exposed to maternal vaccination in utero Longitudinal follow up showed no significant difference in preterm births, neonatal hospitalizations, post-natal hospitalizations...

Contributor: Chris Holmes, MD Educational Pearls: Dr. Carl Reinhold August Wunderlich, of the mid-1800s, was the first physician to suggest temperature was related to disease processes and his measurements set the 37˚C (98.6˚F) as the baseline temperature Thermometers were adapted to be sold to the public with guidelines for temperature measurement interpretation Taller and thinner individuals, an...

Contributor: Jared Scott, MD Educational Pearls: ACEP survey was done in 2018 looking at violence towards staff in the ED with only 10% of those solicited responding Survey found 47% of respondents were assaulted and 71% had witnessed violence towards staff Regarding what was done about the violence, 28% said patients were flagged by the hospital, 21% said patient was arrested by police/hospital s...

Contributor: Peter Bakes, MD Educational Pearls: Tubo-ovarian abscess is a rare complication of pelvic inflammatory disease Usually presents with chief complaint of abdominal pain and is often diagnosed by CT of the abdomen/pelvis Hospitalization is indicated 60-80% of patients improve with an IV anaerobic cephalosporin (cefoxitin or cefotetan) with doxycycline or using clindamycin and gentamicin...

Contributor: Aaron Lessen, MD Educational Pearls: Normal saline is thought to interfere with renal function and cause an acidosis and balanced fluids (like lactated ringers) are a better option The SALT-ED trial and SMART trial showed a small benefit with renal injury and need for dialysis using balanced fluid in critically ill patients Recent multicenter RCT in Brazil evaluated balanced fluids ve...

Contributor: Aaron Lessen, MD Educational Pearls: Techniques regarding ring removal in the ED were evaluated in a recent study which looked at using trauma shears versus the motorized ring cutters A certain type of trauma shear has a ring-cutter attached to it, 7 seconds to remove vs. about 70 seconds for motorized ring cutters Both the users of the devices and the patients preferred the ring-cutt...

Contributor: Aaron Lessen, MD Educational Pearls: Recent study evaluated budesonide for outpatient COVID-19 infection treatment to see if there was a decrease in length of illness or hospitalization rates Found patients who received a budesonide inhaler had recovery times that were about 3 days shorter and there was a slight (non-significant) decrease in hospitalizations References Berezowski I, P...

Contributor: Aaron Lessen, MD Educational Pearls: An endotracheal tube introducer or bougie are often used as a rescue device during difficult intubations as they are small and can be placed blindly Large randomized-controlled trial looked at first-pass bougie use versus standard intubation to determine if there was improvement in first-pass success rate No difference in first-pass success rate, a...

Dr. Kim Nordstrom discusses a valuable bedside tool for evidence-based assessment in patients that visit the ED and are at risk for suicidality. Dr. Nordstrom is a practicing emergency psychiatrist and associate professor with the University of Colorado. As a developer and user of the tool, Dr. Nordstrom gives us invaluable insight into a new avenue for psychiatric care in emergency medicine.   Ed...

Contributor: Aaron Lessen, MD Educational Pearls: Think about giving take home naloxone kits for anyone on long-term opioids as well as anyone with an opioid use disorder, those in opioid withdrawal, or those who recently overdosed on opioids Also consider for individuals with non-opioid substance use disorders For patients seen in the ED with an opioid overdose the 1-year mortality is about 5% an...

Contributor: Nick Tsipis, MD Educational Pearls: Prothrombin complex concentrate (Kcentra)  and Vitamin K are used to reverse life-threatening bleeds in patients on warfarin (Coumadin) Factors II, VII, IX, and X are included in four-factor PCC PCC/Kcentra dosing is 500-2000 units based on INR and patient weight PROPER3 RCT was a non-inferiority trial done to evaluate standardized dosing of PCC/Kce...

Contributor: Nick Hatch, MD Educational Pearls: Botulism requires a prompt clinical diagnosis as lab results can take about 5 days to return Whale blubber, honey, home fermented foods, homemade wine (especially the wine made in prison), and improperly stored canned food can all contain the toxin The botulinum toxin is create by a Clostridium botulinum that is prevalent on our food and in the soil,...

Contributor: Ricky Dhaliwal, MD Educational Pearls: Esophageal food impaction can be managed in the ED prior to calling GI for endoscopy Coca-cola, glucagon, benzodiazepines, calcium channel blockers, and dissolved nitroglycerin are all options to try For pediatric patients, weighted bougies can be used under sedation to attempt retrieval of the food bolus  Always evaluate airway status, especiall...

Contributor: Aaron Lessen, MD Educational Pearls: Biggest study to date examined new protocol for repeat head CT in anticoagulated elderly patients with head trauma and an initial negative head CT 0.5%-6% of patients in this category will get a delayed ICH and this can occur up to a week out from initial injury 18% of the study group had an ICH on initial head CT, but the rest who had negative hea...

Contributor: Alicia Oberle, MD Educational Pearls: Nitrous oxide (N 2 O) can cause a vitamin B12 deficiency in patients after regular use N 2 O is used in procedural sedation but also as a popular recreational drug  N 2 O binds and inactivate B12 in the body, therefore decreasing usable supply Lack of B12, which is essential for myelinating nerves, can lead to subacute combined degeneration of the...

Educational Pearls: Glucagon can be used to treat hypoglycemia and esophageal foreign body, but it can also be used in beta-blocker toxicity to bypass cardiac beta-blockade The superior option for treating bradycardia due to beta-blocker toxicity is glucagon Glucagon has decreased efficacy in patients with heart failure, so increased doses up to 10 mg might be required in the event of beta-blocker...

Contributor: Jared Scott, MD Educational Pearls: A rust ring can occur after a metallic foreign body is left in the eye for a prolonged period of time Issues occur when the rust ring is left as it can epithelialize and become a permanent spot in the patient's vision An eye burr or Alger brush can help to gouge out the rust ring in the emergency setting These tools have a failsafe mechanism to prev...

  Contributor: Aaron Lessen, MD Educational Pearls: Pulse checks are necessary during CPR to check for return of spontaneous circulation (ROSC) Previous studies have shown that assessing ROSC with palpating for pulse are not a very consistent Study compared palpating pulses at carotid/femoral artery versus a newly contrived gold standard for pulse checks The gold standard used was an increase in e...

Contributor: Aaron Lessen, MD Educational Pearls: Study of nearly 400 patients evaluating giving calcium during cardiac arrest with the endpoint as return of spontaneous circulation (ROSC) Compared giving 1 amp calcium chloride with each round of epinephrine for the first two rounds of epinephrine versus saline placebo ROSC occurred in 19% of patients in the calcium groups versus 27% in saline pla...

Contributor: Peter Bakes, MD Educational Pearls: High concern causes of third trimester vaginal bleeding include placenta previa, placental abruption, or vasa previa In placenta previa, the placenta implants over the cervix and this condition Often noted during routine prenatal care on transabdominal ultrasound Patients present with painful vaginal bleeding, usually in the absence of trauma Avoid...