Emergency Medical Minute

Author: Aaron Lessen, MD Educational Pearl: A double ingestion of a single pill is typically a benign event but several drug classes may cause problems A published review of 10 years of single medication double dose ingestion found 12 out of 876 cases had adverse events. The drugs and events were: Propafenone ingestion leading to ventricular tachycardia Beta blocker ingestion leading to bradycardi...

Author: Aaron Lessen, MD Educational Pearls:   Several studies have shown administration of tPA can improve outcomes and reduce need for amputation tPA is considered in grade III and IV frostbite tPA cannot be given until after the warming process Administration is systemically, not catheter directed or intra-arterial References: Jones LM, Coffey RA, Natwa MP, Bailey JK. The use of intravenous tPA...

  Podcast # 437 : Myasthenia Gravis Author: Gretchen Hinson, MD Educational Pearls: Myasthenia gravis (MG) is an antibody mediated autoimmune disorder against the acetylcholine receptors at the neuromuscular junctions. Bimodal age distribution (20's-30's: women; 60's-70's: men) Presents with fluctuating muscle weakness typically worse at the end of the day with upper extremities affected more than...

Author: Charleen Gnisci, PharmD Educational Pearls:   Between 2011 to 2016, Mylan increased EpiPen prices by 400% ($700 for 2 packs) AUVI-Q was recalled in 2012, which left the market share to the EpiPen until recently Teva announced last year it will be making a generic version of the EpiPen retailing around $300 but expected to decrease   References: Kaplan, S. F.D.A. Approves Generic EpiPen Tha...

Author: Ryan Circh, MD Educational Pearls: Ulnar collateral ligament injury is often called gamekeeper's thumb or skier's thumb Can results from traumatic deviating the thumb radially (abduction) Poor rabbits Have a low threshold for referral to hand surgery for follow up - treatment for minor injuries can be conservative but more severe require surgery to preserve function This injury should be p...

Author: Peter Bakes, MD Educational Pearl:   Transient ischemic attack (TIA) is defined as neurologic symptoms that resolve in 24 hours with no new changes on head imaging Mimics include complex migraine, carotid dissection, seizure (Todd's paralysis) Typical presentation is with sudden onset of negative symptoms such as numbness, weakness, etc.  Mimics tend to have positive symptoms such as photo...

Author: Michael Hunt, MD Educational Pearls: Recent study compared ketamine to morphine in elderly patient Ketamine (IV dose 0.3 mg /kg) provided equivalent pain control to morphine  (IV dose 0.1 mg / kg) However, etamine group had much higher rate of side effects, including psychoperceptual A lower does of 0.1 mg / kg given intravenously over 15 minutes might be a better option to start in the el...

Author: Michael Hunt, MD Educational Pearls: As many as 20% of women in assisted living have asymptomatic bacteriuria This can present a diagnostic conundrum when seeing these patients in the emergency department, particularly for altered mental status and deciding whether to treat True diagnosis of UTI in the emergency department is difficult as true diagnoses required culture results and repeate...

Author: Rachel Brady, MD Educational Pearls: Medication errors are estimated to be the 3rd leading cause of death A 2016 study estimated 250,000 errors occur per year, with 7000-9000 leading to death About 50% are in the ordering/prescribing phase; 25-30% during administration phase. Overworked and distracted providers are the most common underlying reasons for medication error A 2017 study found...

  Author: Aaron Lessen, MD Educational Pearls: Choose the longest needle for the humeral IO Internally rotate and adduct the patients hand (resting on umbilicus) for best access to the site Aim 1 cm superior to the greater tuberosity of the humerus with the needle angled 45 degrees inferiorly Maintaining the line is critical - keep arm internally rotated with sling, tape or whatever works     Refe...

Author: Chris Holmes, MD Educational Pearls: In WWI, the 2nd leading cause of soldier disability were STDs. An early treatment of syphilis included topical and inhaled mercury Bloodletting, vitriol, arsenic, and bismuth were other  treatments for syphilis. Infecting patients with Malaria and treating the Malaria was also tried Thankfully penicillin was discovered for our syphilis woes References F...

Author: Gretchen Hinson, MD Educational Pearls: Clinical manifestations of severe hypothyroidism may include: Pale, cool, diaphoretic skin Myxedema is the non-pitting edema seen in hypothyroidism Hypothermia, heart failure, hypotension and shock Shortness of breath Cholestasis, constipation Encephalopathy and coma   Mortality is 30-50% Specific treatment includes thyroid hormone (T3, T4, or both)...

  Author: Eric Miller, MD Educational Pearls:   Recent CDC statement warms against consumption of cookie dough Two common ingredients can pose risk: eggs and flour Flour in dough is a raw agricultural product not treated to kill E. coli A 2016 E. coli outbreak was linked to flour   References: https://www.cdc.gov/features/no-raw-dough/index.html https://www.cdc.gov/ecoli/2016/o121-06-16/index.html...

Author: Katrina Iverson, MD Educational Pearls:   The winter holiday months present a unique picture of patient presentations to the emergency department Some of the unique presentations include: Children falling off Santa's lap Sledding injuries Falling off ladders Lacerations, ingestion, and insertion of broken ornaments (pediatrics) Parents tend to hurt themselves on their children's toys Refer...

Author: Aaron Lessen, MD Educational Pearls: Recent meta-analysis reviewed efficacy oseltamivir (Tamiflu) in pediatric populations treated for influenza, showing an 18 hour reduction in duration of illness for those with laboratory confirmed influenza Those with suspected influenza unsurprisingly had less effect Subgroup analysis showed most benefit in those treated within the first 24 hours of sy...

Author: Mike Hunt, MD Educational Pearls: Measles is highly contagious and successfully infects 90% of those at risk exposed to the virus. 10 day prodrome where patients are asymptomatic. 3 day period of characteristic cough, coryza, conjunctivitis, fever and Koplick spots with a maculopapular rash that moves from head through trunk Infection risk extends three to four days after the onset of rash...

Author: Mike Hunt, MD Educational Pearls:   Blunt cardiac injuries most commonly occur in motor vehicle collisions, auto-pedestrian collisions, and from sports injuries The more anterior right ventricle is the most commonly injured structure Look for new EKG changes such as bundle branch blocks, ST changes, or other arrhythmias New EKG abnormalities should prompt consideration of further workup an...

Author: Jared Scott, MD Educational Pearls:   From 1996 to 2012, the total quantity of opioids prescribed increased 647% for non-cancer pain Office based prescriptions accounted for 84% of the total opioid prescriptions, up from 64% The total share of opioids prescribed from the emergency department declined from 10% to 3.9% but Total opioids prescribed from the ED still increased 219% over this s...

Author: Gretchen Hinson, MD Educational Pearls:   Diabetic ketoacidosis patients are subject to electrolyte derangements Potassium should be monitored closely: K < 3.3 = Do not give insulin and replete K first 3.3 < K < 5.3 = give 20-30mEq K for each L of IVF  K > 5.3 = delay potassium replacement Adult patients are typically severely volume depleted and can require 50 cc/kg bolus or more Insulin...

Author: Don Stader, MD Educational Pearls:   Recent meta-analysis has demonstrated that there is no significant risk for kidney injury from CT contrast Most kidney injury  seen after contrast CTs were due to other underlying illnesses (sepsis, hypovolemia, etc.) Older contrast agents likely did have nephrotoxic effects but this appears to be a thing of the past   References: Aycock RD, Westafer LM...

Author: Don Stader, MD Educational Pearls:   Etripamil is an intranasal calcium channel blocker in development for use in SVT A recent study showed that etripamil has an SVT conversion rate of around 80% Etripamil does not have the same feeling of "impending doom" that can occur with adenosine Editor's note: Etripamil is still in development and these results are from a phase II clinical trial .  ...

Author: Don Stader, MD Educational Pearls: Vertebral artery dissection (VAD) contributes to just 2% of strokes overall but ~25% of strokes for patients < 30 VAD is associated with minor trauma (chiropractic manipulation, yoga), typically with neck extension and rotation. VAD can cause posterior stroke symptoms (vertigo, diplopia, Horner's Syndrome , Wallenberg Syndrome ) Overall a good prognosis w...

Author: Katie Sprinkle, MD Educational Pearls: Hyponatremia results when patients over hydrate and dilute their sodium with too much free water Symptoms of hyponatremia can mimic symptoms of dehydration (dizziness,  lightheadedness, general malaise) With severe hyponatremia patients can progress to seizure, coma, and death Hypernatremia results from dehydration and is more common References: Benne...

Author: Aaron Lessen, MD Educational Pearls: Defined as QRS over 120 ms and rate over 120 Two major rhythms = Vetricular tachycardia (VT) or SVT with aberrancy Safest approach is to assume it is VT Synchronized Cardioversion is preferred even for stable VT for multiple reasons including safety and efficacy Procainamide is preferred pharmacologic option Amiodarone is less preferred third option Cal...

Author: Ryan Circh, MD Educational Pearls: Myofascial pain syndrome (MFPS) is typically unilateral with discrete points of palpable pain Often secondary to repeated use and poor posture. MFPS typically responds very well to trigger point injections. Fibromyalgia is bilateral and diffuse and is thought to have a psychological component Some of the best pharmacological treatments for fibromyalgia ar...