Emergency Medical Minute

Contributor: Don Stader, MD Educational Pearls: The eye is surrounded by relatively inflexible tissues such as the bone of the orbit and the fibrous tissue of the eye. This makes it relatively susceptible to damage from outside compression, which is most common from trauma. This phenomenon is called ocular compartment syndrome (OCS)  Look for OCS when patients have face, head or direct eye trauma ...

Contributor: Dylan Luyten, MD Educational Pearls: Those that are hypokalemic are often hypomagnesemic, and should receive magnesium (Mg) supplementation if repleting potassium Mg levels are typically not necessary - if someone is suspect to have hypomagnesemia, just given them Mg Mg increases the AV node refractory period and therefore may be helpful as an adjunct to those in atrial fibrillation w...

Contributor: Aaron Lessen, MD Educational Pearls: Patients with psychiatric complaints are often complicated to disposition from the main ED, and many will require inpatient psychiatric stays Some health systems have dedicated psychiatric ED's that are specialized in taking care of these patients For example, in Oakland, CA, EMS are permitted to "clear" a patient for transport to a psych-only faci...

Author: Jared Scott, MD Educational Pearls: Study from Hennepin County EM studied the efficacy of different drugs for agitation, which included 737 patients Most patients in this study were male and *surprise* drunk Compared doses of common sedatives with primary outcome of sedation at 15 minutes (all intramuscular) haloperidol 5 mg ziprasidone 20 mg olanzapine 10 mg midazolam 5 mg haloperidol 10...

Treatment with buprenorphine is easier, less time consuming and far more effective for management of opioid withdrawal and OUD than standard care with clonidine, IVF, haldol and other symptomatic therapies.  Induction with buprenorphine is easy, requires no IV or labs, and is usually accomplished in 1-2 hours. It requires a chair, not a hospital bed.  To identify patients who are candidates, be su...

There are three MAT drugs available to treat addiction: naltrexone (brand name Vivitrol), methadone (brand names Dolophine or Methadose) & buprenorphine (brand name Suboxone, Subutex, and Sublicade).  The only MAT drug appropriate for initiation in the ED is buprenorphine. Buprenorphine is a semi-synthetic opioid which acts as partial agonist at the mu receptor. Buprenorphine does not produce as m...

Medication Assisted Treatment or (Medication for Addiction Treatment) is an important frontier in ED care of patients with Opioid Use Disorder. Naltrexone, methadone and buprenorphine are the medications approved for the treatment of OUD. Addiction is a disease that is widely misunderstood and rarely taught in medical school.  It is a dangerous myth that the best treatment of all addictions is sim...

Addiction is widely misunderstood by the public and by many healthcare providers. It is not taught in most medical schools.  Combating the opioid epidemic will require providers to understand Opioid Use Disorder (OUD) and its treatment. Addiction is a chronic, relapsing disease with extraordinarily high morbidity and mortality. It is the transition from controlled to impulsive and compulsive drug...

Author: Dave Saintsing Educational Pearls: Poor sleep is an independent risk factor for development of health problems such as type 2 diabetes.  A 2019 study, randomized participants to 3 groups: 9 hours of sleep, 5 hours of sleep with weekend catch-up sleep, and 5 hours of sleep without catch-up sleep.  In the sleep deprived (5 hour) groups, there was significantly more insulin resistance, calori...

Podcast # 499: Posterior Circulation Strokes Contributor: Neal O'Connor, MD Educational Pearls: Dizziness is a very common complaint in the emergency department, but how can we find patients with a dangerous cause of their symptoms, namely a posterior circulation stroke? Consider a posterior circulation stroke in those with an abrupt onset of headache with neck pain, balance problem, blurred visio...

Author: Susan Ryan, DO Educational Pearls: General orthopedic principles: Examine above and below the injury Document neurovascular status X-ray imaging typically requires three different views Fracture description should include name the bone, location of fracture, degree of displacement, and if it is closed or open Osgood-Schlatter (tibia) and Sever's (calcaneus) disease are apophyseal injuries...

Author: Dylan Luyten, MD Educational Pearls: While certain aspects of the history, exam, and EKG may increase likelihood of ACS, there is no one element that performs well on its own  Elements of the history have been found to have different likelihood ratios, which can increase or decrease the probability of a patient having ACS Likelihood ratios greater than one increase the chance of the patien...

Author: David Holland, MD Educational Pearls: Hallucinogenics have been used for a variety of cultural and religious reasons for thousands of years In the 1960's a Harvard professor began experimenting with psilocybin mushrooms. There was resulting public outcry, eventually leading to all hallucinogens being listed as schedule I drugs Common hallucinogens include: LSD (acid), Mescaline (peyote), D...

Author: Rachel Brady, MD Educational Pearls: Elderly patients (>65 years old) have a higher trauma mortality compared to younger patients, even though they have lower mechanisms of injury  Elder trauma is often under-triaged due to low-energy mechanisms and lack of physiologic response due to age and medications such as beta-blockers. Do not be reassured by normal vital signs.  Image elderly patie...

Contributor: JP Brewer, MD Educational Pearls: Obtaining collateral is often vital to determine the potential drugs accessible to the patient - this may include After this, use ancillary sources such as EMS, family/friends, and police to determine the patient's last normal, PMH and medications To help separate toxidromes , pupillary exam and skin exam are helpful Important physical exam clues in t...

Contributor: JP Brewer, MD Educational Pearls: Because of their smaller size, there are a variety of adult-dose pills that are potentially toxic to children.  The most common categories of medications that may be toxic include cardiac, diabetic, pain, psychiatric, anti-malarial, and herbals/caustics  Oral hypoglycemics such as sulfonylureas can be particularly dangerous in children.  Opiates and b...

Contributor: Don Stader, MD Educational Pearls: Buprenorphine is a partial Mu-agonist and binds with higher affinity than most opioids Pain management with opioids therefore can be difficult in patients taking buprenorphine Ketamine is a good option for pain control in these patients You can also consider using additional buprenorphine Intravenous buprenorphine is dosed differently than oral formu...

Educational Pearls: Buprenorphine is a semi-synthetic derivative of the opium poppy FDA approved for the treatment of opiate use disorder and chronic pain Benefit in emergency department use is the ceiling effect - producing less euphoria as well as respiratory depression with higher doses  It has an onset of 30-60 minutes, peak effect at 1-4 hours Duration of action depends is dose dependent, typ...

Contributor: Don Stader, MD Educational Pearls: Syncope is usually benign but can be caused by serious etiologies which include: PE, certain cardiac arrhythmias, AAA, intracranial bleed/stroke The Canadian Syncope Rule appears to identify those patients with syncope and low risk of serious outcomes The score is based on vital signs, EKG and history Negative scores preclude a very low risk of adver...

Contributor: Jared Scott, MD Educational Pearls: The CDC recommends rabies prophylaxis if there was a direct encounter with a possibly rabid animal except... Bats are treated differently since their bites may be very superficial and not seen/felt. All people with possible close encounters with a bat should receive rabies prophylaxis  From 1990-2007 there were 34 rabies cases associated with bats:...

Contributor: Nick Hatch, MD Educational Pearls: Dalbavancin (Dalvance®) is an antibiotic that can be used for skin and soft tissue infections, providing MRSA coverage It cannot be used in other infections or sepsis Dalbavancin may be appealing as a single dose lasts about 2 weeks Expense is currently a large barrier to use Patients with a vancomycin allergy will likely be allergic to Dalbavancin a...

Contributor: Michael Hunt, MD Educational Pearls: Due to the efficacy of vaccination, epiglottitis is now more common in adults than children Risk factors include smoking and other immunocompromising co-morbidities, such as diabetes Epiglottitis can present with sore throat and fever, with potential rapid progression to respiratory distress and stridor Diagnosis can include x-ray to look for the "...

Contributor: Nick Hatch, MD Educational Pearls: True morel mushrooms are commonly foraged The false morel mushroom ( Gyromitra esculenta ) looks similar to the true morel, but is toxic False morel mushroom toxicity can cause gastrointestinal symptoms as well as liver failure, rhabdomyolysis, and seizures Seizures can be refractory to benzodiazepine therapy and may require use of vitamin B6 and pro...

Contributor: Jared Scott, MD Educational Pearls: Cerebellar strokes make up a disproportionate number of missed or delayed diagnosis for stroke likely due to the subtle nature of the presentation Cerebellar strokes can present with vomiting, dizziness, and ataxia.  Unlike anterior circulation stroke, exam findings in a cerebellar stroke are ipsilateral to the lesion  On neuro exam, findings may in...

Contributor: Charleen Gnisci, PharmD Educational Pearls: Causes of increased intracranial pressure may include intracranial hemorrhage, malignancy, and trauma.  While definite treatment is to remove the offending cause, there are emergency medicine   Non-pharmacologic methods include elevating head of bed and removing noxious stimuli Pharmacologic options include mannitol and hypertonic saline Hyp...