Emergency Medical Minute

Contributor: Don Stader, MD Educational Pearls: Antiplatelets include aspirin and clopidogrel, and are generally used for arterial clotting (MI, stroke) Anticoagulants such as coumadin, Xarelto, Eliquis are generally used for venous clotting (DVT/PE) Growing data suggests that dual antiplatelet therapy (aspirin+clopidogrel) is superior to aspirin alone in reducing stroke for diagnosed with TIA Ref...

Contributor: Michael Hunt, MD Educational Pearls: Tetracycline antibiotics such as minocycline can cause greyish hyperpigmentation This hyperpigmentation can sometimes be reversible but not always Minocycline has been used for its effects in autoimmune and neurological diseases, where it is  often taken chronically, which can lead to increased pigmentation   References La Placa M, Infusino SD, Bal...

Contributor: Peter Bakes, MD Educational Pearls: While there are many different types of medical error, one of the most common errors in emergency medicine is failure to diagnose Systematic error in thinking that negatively affects judgement Medical errors are often driven by cognitive biases, which include anchoring, attribution, and availability   Anchoring bias occurs when early information lea...

Author: Sam Killian, MD Educational Pearls: Abuse occurs by breathing in volatile substances such as solvents, glues, paints, butane, and propane Inhalants are generally depressants Estimated that 100-125 people die every year in the US from acute inhalant abuse. Short-term effects include memory impairment, slurred speech, diplopia, seizures, and cardiac arrhythmias Long term effects include rena...

Author:  Nick Hatch, MD Educational Pearls: Pregnancy is a hypercoagulable state, which predisposes women to venous thromboembolism, but also elevates levels of circulating d-dimer A recent study evaluated the YEARS protocol in combination of adjusted d-dimer cutoffs in pregnant women to evaluate for DVT and PE Using this protocol, only 1 DVT was missed. No PE's were missed. This protocol has grow...

Author: Chris Holmes, MD Educational Pearls: Hallucinogenic drugs have been in use since ancient times for both medical and recreational purposes Ayahausca is an ancient psychedelic with origins in Bolivia that causes intense vomiting followed by a psychedelic experience This and other hallucinogens are gaining gaining interest for their use in depression with some startling positive initial resul...

Author:  Nick Hatch, MD Educational Pearls: Postpolypectomy electrocoagulation syndrome (PES) is a rare complication of polypectomy and electrocautery during colonoscopy Occurs when cautery causes transmural thickening from a contact burn Patients can present as if they have peritonitis, with guarding, leukocytosis, fever, etc. CT is the imaging of choice mainly to evaluate for bowel perforation a...

Author: Dylan Luyten, MD Educational Pearls: Actual wait times are weakly correlated to patient satisfaction but the difference between perceived/expected wait times and actual wait times is strongly correlated Having others in the room or with the patient while they wait also has a positive effect Under-promising and over-delivering can result in better patient experience Managing up others and s...

Author: Michael Hunt, MD Educational Pearls: A recent study evaluated the relationship between abnormal orthostatic vital signs and serious outcomes within 30 days in patients over 60 presenting to the ED with syncope Of the roughly 2000 patients enrolled, about ⅓ had abnormal orthostatic vital signs There was no statistically significance between orthostatic vital signs and serious outcomes in 30...

Author: Peter Bakes, MD Educational Pearls: The differential diagnosis for pedal edema includes issues in the heart, kidney, and liver Obesity hypoventilation syndrome (OHS) is an important and common cause of right heart failure. Nighttime hypoventilation leads to pulmonary hypertension, causing right heart strain followed by right heart failure OHS criteria includes obesity, sleep disordered bre...

Author: Sam Killian, MD Educational Pearls: A recent study in Pediatrics compared the rates of antibiotic prescriptions for acute respiratory infections (ARIs) between direct to consumer (DTC) telemedicine, urgent care, and primary care providers Among the nearly 530,000 visits studied, the rate of antibiotic prescription was 52%, 42% and 31% for telemedicine, urgent care, and primary care provide...

Author: Gretchen Hinson, MD Educational Pearls: In most healthcare settings, normal saline (NS) has become ubiquitous as an intravenous fluid despite some potential drawbacks Compared to normal saline, a balanced crystalloid (either lactated Ringer's or Plasma-Lyte) was associated with a lower composite endpoint of mortality, renal replacement therapy, and renal injury in SMART (Isotonic Solutions...

Author: Don Stader, MD Educational Pearls: Cyclic vomiting syndrome (CVS) is different than cannabis hyperemesis syndrome (CHS). It is important to differentiate the two. CHS is thought to be caused by activation of THC receptors in the gut CVS is associated with migraines and therefore responds to similar medications Olanzapine (Zyprexa) is an alternative to haloperidol (Haldol) Amitriptyline, as...

Author: Jared Scott, MD Educational Pearls: Ondansetron (Zofran) is one of the latest drugs that has had concerns raised about side effects, particularly in pregnancy 2018 study probed two birth defect databases to assess increases in 51 major birth defects with increased exposure to ondanse tron Only two of the 51 had even a modest increase, w hich is unclear in causation (cleft palate and renal...

Author: Dave Rosenberg, MD Educational Pearls: Nothing by mouth (NPO) status routinely used before surgery to reduce the theoretical risk of aspiration However, surgery poses a large physiological stress. Calories and fluid are needed to overcome stresses like these Patients who drank 1/2 strength Gatorade up to 2 hours before surgery did better than those who did not References Alyssa Cheng-Cheng...

Educational Pearls: Tiflitis refers to the presence of enterocolitis in the setting of neutropenia - also known as neutropenic enterocolitis Commonly a result of chemotherapy for hematologic malignancies. The infection is usually polymicrobial/fungal and can lead to septic shock Usually presents with fever, abdominal pain, with associated GI complaints Workup includes CBC for the ANC (usually

Author: Erik Verzemnieks, MD Educational Pearls: Cauda equina syndrome is caused by the compression of the nerve roots that extend beyond the termination of the spinal cord Trauma, infection, hematoma, disc rupture/herniation can cause this - basically anything that can cause pressure and fill space Symptoms can include saddle anesthesia, lower extremity pain, numbness, incontinence, and constipat...

Author: Nicholas Hatch, MD Educational Pearls: Measles has a period of infectivity starts before the appearance of the characteristic rash, up to 4-5 days A devastating consequence of measles is Subacute Sclerosing Panencephalitis (SSPE), which manifests 7-10 years after the initial measles infection SSPE is a central nervous system disease that has no cure and is nearly universally fatal Educatin...

Author: Ryan Circh, MD Educational Pearls: The 2019 ANDROMEDA-SHOCK trial compared using serum lactates to capillary refill assessment in septic shock patients to guide resuscitation Capillary refill time was standardized (this is not straightforward): A glass microscope slide was pressed on the ventral side of the right index finger Pressure was increased until the skin was blanched This pressure...

Author: Aaron Lessen, MD Educational Pearls: A problem of take-home-naloxone is the administration of it by an able-bodied bystander Australian study looked at consecutive opioid overdose deaths in a single year to identify characteristics of overdose and potential for bystander administered naloxone Of the 235 fatal heroin overdoses reviewed, 83% were alone with only 17% (38 cases) having another...

Author: Erik Verzemnieks, MD Educational Pearls: Buproprion is used as an antidepressant and for smoking cessation Severe buproprion overdoses can cause seizures and lead to cardiac dysrhythmias Benzodiazepines are treatment of choice for seizures Bicarbonate and Interlipid are also possible treatment options with less evidence References Stall N, Godwin J, Juurlink D. Bupropion abuse and overdose...

Author: Don Stader, MD Educational Pearls: 10% of patients seen in the emergency department for opioid overdose patients will die within a year Half of these overdoses will occur in the next month This mortality rate is higher than patients with STEMI, of which 7% will die within one year Take-home naloxone, as well as medication assisted treatment like buprenorphine can save lives References Olfs...

Author: Gretchen Hinson, MD Educational Pearls: Breath stacking occurs when a patient is unable to expire fully before another inspiration In intubated/ventilated patients, this is because adequate time has not passed before exhalation Asthmatics are susceptible due to the prolonged expiratory phase Complications can include reduction in cardiac preload and cardiovascular collapse Pursed-lip breat...

Author:  Michael Hunt, MD Educational Pearls:   Most causes of syncope are benign Pulmonary embolism can result in syncope and is life threatening A recent study of Canadian and US ED patients with syncope showed that 0.4% of patients had a PE at 30 day follow-up PE should always be considered in cases of syncope but overall is a rare cause   Editor's note: this study puts to rest a previous study...

Author:  Julian Orenstein, MD Educational Pearls:   Severe clonidine ingestion can present as a fluctuating mental status between typically accompanied by changes in vital signs (hypotension/bradycardia) Respiratory depression requiring intubation is not uncommon   References Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia and central nervous system depre...