Emergency Medical Minute

Contributor: Peter Bakes, MD Educational Pearls: Hyperacute T waves can occur immediately and typical last less than an hour Hyperacute T waves are typically broader than peaked T-waves, which are associated with hyperkalemia ST elevation which usually starts within an hour of the inciting event and can last up to a few days, and often follows the hyperacute T-waves Q waves can begin at the time S...

Contributor: Jared Scott, MD Educational Pearls: EKGs look at different angles, or vectors, of the heart's electrical conduction as it travels through the heart. Knowing how to read these vectors is essential in diagnosing locations of cardiac pathologies   Leads II, III, and aVF follow an inferior path, so ST elevation in those leads indicates inferior involvement Major complications more common...

Contributor: Peter Bakes, MD Educational Pearls: STEMI criteria is not just 1mm elevation in contiguous leads 1.5 mm in V2-V3 for women 2.0 mm in V2-V3 for men 2.5 mm in V2-V3 for men under 40 Inferior MI typically have ST elevation in leads II, III and aVF Usually inferior MI's show reciprocal changes (ST depression) in the lateral leads. Lateral MI typically elevation in V5, V6, I, and aVL Anter...

Contributor: Aaron Lessen, MD Educational Pearls: High flow nasal cannula (HFNC) has become more utilized with COVID pandemic Multiple studies have shown this method improves both oxygenation and ventilation Newer studies have shown the respiratory benefit of HFNC  vs normal oxygen in patients suffering from CHF and those with do not intubate orders who are experiencing respiratory distress.   Hea...

Contributor: Ruben Marrero-Vasquez, PharmD Educational Pearls: ACEP and FDA have both issued warnings about the viral Tik Tok Benadryl (diphenhydramine) challenge where individuals voluntarily overdose on diphenhydramine which can cause fatal toxicity Diphenhydramine is typically dosed at 0.5-1 mg/kg in pediatric patients Q4-6 PRN and carries a fatal dose of 20-40 mg/kg but anywhere from 3-5x reco...

EMM is excited to welcome back the hosts of Millennial Mental Health Channel podcast to explain the key points of a robust suicide assessment in the ED. Dr. Justin Romano is a third year psychiatry resident in Omaha, Nebraska and Eddie Carrillo is a licensed mental health therapist currently working at partial hospitalization and IOP eating disorder program in Portland, Oregon. Their podcast Mille...

Educational Pearls: The CDC has made new formal recommendations for treating Gonorrhea due to increasing resistance to Rocephin and Azithromycin. New recommendations: Confirmed gonorrhea: Ceftriaxone 500 mg once Empiric treatment: Ceftriaxone 500 mg once followed by 7 days Doxycycline 100 mg BID No longer using Azithromycin due to high resistance Second line: Gentamycin IM Cefixime 800 mg oral Pha...

Contributor: Tom Seibert, MD Educational Pearls: High altitude cerebral edema (HACE) is the end stage of acute mountain sickness and is diagnosed when patients develop neurologic dysfunction, ataxia, and altered mental status.   The pathophysiology of HACE is thought to be due to increased cerebral blood flow and increased capillary permeability causing vasogenic edema and brain swelling HACE is l...

Contributor: Don Stader, MD Educational Pearls: Time can be an important factor in outcomes regarding sepsis including mortality Emphasis has grown on early administration of antibiotics and IV fluids in sepsis However, early initiation of vasopressors for hypotensive patients may have significant mortality benefit as well References Hayden GE, Tuuri RE, Scott R, et al. Triage sepsis alert and sep...

Contributor: Tom Seibert, MD Educational Pearls: Acute Mountain sickness (AMS) can cause headache along with fatigue, nausea, vomiting, insomnia Typically occurs above 6500 feet ( not 65,000 ) in elevation   Acclimation to altitude can help prevent symptoms if not treated, AMS can advance to severe illness involving cerebral or pulmonary edema. Mild symptoms can be managed with rest but more sever...

Contributor: Thomas Seibert, MD Educational Pearls: High Altitude Pulmonary Edema (HAPE) typically occurs 2-4 days after arriving at elevation Symptoms include: Fatigue Dyspnea Cough Treatment includes: Descent to lower elevation  Oxygen supplementation Nifedipine Caused by sympathetic stimulation from hypobaric hypoxic exposure, causing uneven pulmonary vasculature constriction and when paired wi...

Contributor: Aaron Lessen, MD Educational Pearls: Schizophrenia typically doesn't present until age 13 and has a prodrome Prodrome includes months of gradual changes in behavior, starting with negative symptoms and progressing to positive symptoms Negative symptoms include losing concentration, poor memory, poor school performance, and personality changes Positive symptoms include hallucinations,...

Contributors: Rachael Duncan, PharmD and Sean McCullough, PharmD Educational Pearls: A 2019 Report by the National Women's Law Center: Most common occupations for pregnant workers are elementary and middle school teachers, registered nurses, and nursing/psychiatric/home health care aides.  This raises the question: Should pregnant women, specifically front-line workers, get the Covid-19 vaccine? ...

  Contributor: Aaron Lessen, MD Educational Pearls: Serum prolactin levels can be used to help differentiate epileptic seizures from non-epileptic seizures It is also released and elevated after epileptic seizures but not non-epileptic seizures A level must be checked 10-20 minutes after the episode and if possible a next day level should be checked to establish a baseline Levels can also be raise...

Contributor: Don Stader, MD Educational Pearls: Zyprexa (olanzapine) is a second generation antipsychotic with multiple other uses Excellent for treating nausea in patients undergoing chemotherapy or with THC hyperemesis syndrome Helps with the psychological and emotional aspect of pain Effective in treatment of headaches Can be given under the tongue Fewer incidences of dystonic reactions compare...

Contributor: Don Stader, MD Educational Pearls: Majority of patients experience side effects while taking opioids Most common include nausea/vomiting, puriitis, constipation; more severe and less common include respiratory depression, addiction and overdose Opiates can cause nausea, but ondansetron (Zofran) is the wrong treatment because it's not antidopaminergic. Instead consider using metoclopra...

Contributor: Peter Bakes, MD Educational Pearls: Recent study looked at if mask wearing protects the mask wearer from infection This group found 1.8% of mask wearers got COVID while 2.1% of non-mask wearers became infected, which was not statistically significant This was not statistically significant and has been used to justify not wearing masks by some groups While the numbers look small, it's...

Contributor: Rachael Duncan, PharmD Educational Pearls:  ED visits nationwide declined by 42% in April 2020 compared to the same time in 2019 largely due to the fear of the COVID-19 pandemic. The biggest decline was seen in pediatrics less than 14, women and emerging COVID hotspots like the Northeast. In recent weeks, this trend has reversed, showing a record-breaking number of COVID cases, hospit...

For this episode of Mental Health Monthly, EMM is honored to collaborate with the hosts of Millennial Mental Health Channel podcast to explain Borderline Personality Disorder and tips to manage patients with this diagnosis in the Emergency Department. Dr. Justin Romano is a third year psychiatry resident in Omaha, Nebraska and Eddie Carrillo is a licensed mental health therapist currently working...

Contributor: Aaron Lessen, MD Educational Pearls: Contrary to many assumptions, meter-dose inhalers (MDIs) are as effective as nebulizers in pediatric and adult patients Nebulizers are associated with higher rates of tremor, tachycardia; they cost more and are associated with longer ED stays Though it may take some convincing, in a patient that is physically able, using an MDI with spacer appears...

Contributor: Ryan Circh, MD Educational Pearls: Diabetic ketoacidosis (DKA) can be the initial presenting condition of undiagnosed diabetes type I in pediatric patients Unlike adults, children typically need less fluid (i.e. 10 mL/kg bolus for those in shock followed by maintenance) Cerebral edema is a concern from rapid administration of fluids An insulin drip at 0.1 units/Kg/hr should be started...

Contributor: Nick Tsipis, MD Educational Pearls: Perichondritis involves infection of not only the connective tissue of the ear but typically the cartilage as well Symptoms include erythema, ear pain, and fevers The most common bacterial cause is Pseudomonas. Perichondritis often occurs after a wound or piercing, but trauma is not necessary for the infection to occur Anti-pseudomonal coverage is e...

  Contributor: Sam Killian, MD Educational Pearls: Spontaneous bacterial peritonitis (SBP) is an infection of peritoneal fluid that typically occurs in cirrhotic patients Symptoms may include abdominal pain, fever, and/or altered mental status Paracentesis is diagnostic test of choice. Diagnostic criteria includes > 250 polymorphonuclear cells (PMNs) or a positive gram stain/culture Treatment is t...

Contributor: Rachael Waterson, PharmD Educational Pearls:  Drug shortages have been an ongoing issue since the 2000's. Improvement was being made; however, several factors have exacerbated the drug supply more recently. According to the US Food and Drug Administration (FDA) Report there are 163 drugs currently on the drug shortage list. Of the 40 drugs critical to treating COVID-19, 18 are on this...

Dr. Tsipis sits down with colleague Dr. Ricky Dhaliwal for some insightful conversation regarding the differences between academic and community settings as well as the various roles of advocacy in medicine.  Time Stamps 00:23 Banter and introductions 2:41 upbringing in 1st generation immigrant Indian household 14:30 losing culture as 2nd gen immigrant 7:32 Balancing family and work with a two doc...