Emergency Medical Minute

Author: Nick Hatch, MD Educational Pearls:   A recent study investigated the effect of scheduled IV acetaminophen on the incidence of delirium in post-CABG patients in the ICU The use of scheduled IV acetaminophen reduced the rate of delirium in these patients compared to placebo This may be due to the analgesic effect of acetaminophen and/or less requirement on other deliriogenic medications (opi...

Author: Jared Scott, MD Educational Pearls:   Modified Rankin Score:  measure of disability often used to qualify outcomes following stroke  = no disability, 6=dead, 0-1 indicate good outcome) 0-6 Scale 0-1 indicative of good outcome ASPECT score: uses CT to quantify the extent of changes in the brain due to ischemia 0-10 Scale 10 areas are assessed on non-contrast CT to assess for early stroke ch...

Author: Jared Scott, MD Educational Pearls:   Beta-blockers can mask the effects of hypoglycemia Prolonged/refractory hypoglycemia should raise a suspicion for sulfonylurea (or other oral hypoglycemic) overdose Interventions to reverse hypoglycemia include feeding the patient, IV dextrose, glucagon Octreotide can be used as an antidote with sulfonylurea ingestion  Editor's note: Here is an interes...

Author: Michael Hunt, MD Educational Pearls:   Like all tests, urine toxicology (utox) screens can have false positives Prescription medications such as demerol, antipsychotics, ketamine, and tramadol can all produce a false positive utox for PCP Over-the-counter medication such as dextromethorphan also mimic PCP on utox   References Doyon S. (January 2014). False Positive Urine Screens for Phency...

Educational Pearls:   Acetaminophen overdose can also present in patients taking too much over the course of days to weeks - not just intentional ingestions If acute overdose is suspected, refer to the Rumak-Matthew nomogram to guide treatment based on time of ingestion and the time of level In chronic overdose, Tylenol levels will not guide treatment NAPQI is the toxic metabolite of acetaminophen...

Author: Sam Killian, MD Educational Pearls:   Headache is a common complaint in the ED. It's plausible that headaches could be correlated with environmental factors A 2015 study ED visits for headache found that temperature was associated with an increase visits, while higher humidity led to fewer A retrospective study looking over a 10-year period for headache found that there was an increase hea...

Author: Sam Killian, MD Educational Pearls: Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) occurs in 1:100000 individuals The disease is caused by a defect in the NOTCH3 gene on chromosome 19 It is an important cause of stroke in young patients Features include ischemia, cognitive deficits, migraines, psychiatric disease, coma, and seizure, all...

Author: Don Stader, MD Educational Pearls: Non-steroidal anti-inflammatory drugs (NSAIDs) are effective pain relievers but come with important side effects NSAIDs inhibit COX-1 and/or COX-2, which decreases the production of prostaglandins, which reduce pain and inflammation Side effects of NSAIDS include increased rates myocardial infarction, stroke, and gastrointestinal bleeding, CVA Effective p...

Author: Sam Killian, MD Educational Pearls: Viral gastroenteritis alters the gut microbiome and it is theorized that probiotics may help reduce the duration and severity of the disease. Double-blind randomized controlled trial involving almost 900 children with viral gastroenteritis compared 5 days of probiotics to a control group. There was no difference in the rates of severe gastroenteritis bet...

Author: Dylan Luyten, MD Educational Pearls: A "banana bag" is a bag of IV fluid that contains various vitamins and minerals including folate and thiamine IV fluids do not alter intoxicated patients recovery in the emergency department Folate deficiency is rare in the intoxicated patient Some intoxicated patients may be thiamine deficient, and those that would benefit the most need significantly m...

Author: Ryan Circh, MD Educational Pearls: Chronic salicylate (ASA) toxicity can present in elderly patients as altered mental status Consider chronic toxicity in patients with an unexplained anion gap acidosis Treatment for chronic ingestion typically  includes IV fluids and urine alkalinization References: O'Malley GF. Emergency department management of the salicylate-poisoned patient. Emerg Med...

Author: Dylan Luyten, MD Educational Pearls: Recent randomized controlled trial compared intravenous to oral acetaminophen in emergency department patients There was no difference in pain relief between the groups While the actual acquisition cost of these drugs are not significant, the cost multipliers that are passed onto patients lead to real dollars With the significant cost of IV acetaminophe...

Author: Dylan Luyten, MD Educational Pearls: 1:500 patients will experience a retinal detachment Consider stroke on your differential (central retinal arterial occlusion) Flashes and floaters are a common complaint with retinal detachments Though patients may report fields of vision loss, visual acuity is often spared Ocular ultrasound is an effective way to diagnosis retinal detachment in the ED...

Author: Michael Hunt, MD Educational Pearls: Bedside transtracheal ultrasound to confirm proper endotracheal intubation is simple and effective Review of 17 studies showed transtracheal ultrasound was was 98.7% sensitive and 97.1% specific Curvilinear probe may be preferable as it provides a larger field of view Editor's Note: rather than explain what you're looking for… just go here References: G...

Author: Aaron Lessen, MD Educational Pearls: Dyspnea can occur in up to 50% of intubated patients Dyspnea is associated with prolonged mechanical intubation Often goes undiagnosed as these patients have difficulty communicating Expert opinion on reducing sensation of dyspnea Reduce stimulation of respiratory drive like fever and acidosis Give bronchodilators for patients with wheezing Optimize the...

Author: Sue Chilton, MD Educational Pearls: Measles is highly contagious Typically patients just look sick Remember 4 & 4, 14, and 4-C's: Contagious 4 days before and after onset of rash 14 days for rash to appear Cough, coryza, conjunctivitis (non-purulent), and Koplik's spots Under 2 and over 20 are highest risk groups 1 in 1000 will die Subacute sclerosing panencephalitis is one of  the most fe...

Author: Jared Scott, MD Educational Pearls:   CXR is 40-90% sensitive for detecting pneumonia when compared to CT Patients with a high degree of suspicion for pneumonia may still warrant treatment despite a negative CXR   References: Self WH, Courtney DM, McNaughton CD, Wunderink RG, Kline JA. High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patien...

Author: Don Stader, MD Educational Pearls:   Recent study demonstrated patients with non-STEMI treated with heparin had no difference in survival, but had an increased risk of major bleeding Heparin may be an outdated medication in the era of dual anti-platelet therapy and PCI Heparin may fall to the wayside like other former treatments for ACS such as morphine, oxygen and nitroglycerin as far as...

Author: Katie Sprinkle, MD Educational Pearl:   Carbon monoxide (CO) is the leading cause of death from poison world-wide CO forms from the combustion of any carbon based product Patients often present with non specific symptom like headache, vomiting, and malaise Consider this diagnosis with multiple people presenting with similar symptoms from a single location Treatment is with high flow oxygen...