Emergency Medical Minute

Author: Dylan Luyten, MD Educational Pearls:   Symptoms of acute limb ischemia are the 5 P's: Pulselessness, pain, pallor, paresthesias, and poikilothermia Sudden onset of non-traumatic extremity pain should raise concern for this diagnosis Obtaining an ankle brachial index (ABI) can help confirm the diagnosis Consultation with vascular surgery should be immediately after the clinical diagnosis an...

Author: Katie Sprinkle, MD Educational Pearls:   The fascia iliaca block is useful for hip and proximal femur fractures. Typically involves injecting 40-60 mL of diluted bupivacaine (0.25%) under the fascia iliaca (or other anesthetic) Anesthesia is achieved of the femoral, obturator, and lateral femoral cutaneous nerves. Monitor for signs of bupivacaine toxicity (paresthesias, AMS, seizures, arrh...

Author: Aaron Lessen, MD Educational Pearls: Patients with "minor" strokes with NIHSS 0 to 5  can still end up having poor long-term outcomes Recent study compared use of alteplase vs. aspirin for these patients and saw no difference in regards to favorable neurologic outcome at 90 days Study was ended early due to patient recruitment difficulties Editor's note: though ended early, it is debatable...

  Author: Dylan Luyten, MD Educational Pearls:   Early recognition that the current situation is a mass casualty incident (MCI) is essential with establishing a sole provider/nurse to oversee Team members labeling themselves by name and role is also helpful Practice and prepare for these unfortunate events   Editor's note: This podcast comes at the end of a MCI drill over several days References:...

Author: Aaron Lessen, MD Educational Pearls: Retrospective study looking at type of transportation and mortality outcomes for patients with penetrating trauma Mortality was 2.2 % for those brought in by private vehicle compared to 11.6% by EMS     Editor's note: the above is raw mortality - even after risk adjustments the odds ratio of death was statistically significant for penetrating injuries,...

Author: Nick Hatch, MD Educational Pearls:   Quick review on typical treatments for acute CHF: Nitrates are a mainstay to reduce preload Furosemide has fallen out of favor in regards to urgency but still essential; it can also be utilized in those with poor renal function Before going into the weeds: Phlebotomy can be used to remove volume and may be helpful in certain clinical scenarios Trapping...

Author: Don Stader, MD Educational Pearls: Recent study showed efficacy 5mg IM midazolam > 10mg IM olanzapine > 10mg IM haloperidol for quickly sedating an agitated patient If you have access, ketamine intravenous is the fastest Olanzapine should be used with caution in elderly patients because of its anticholinergic properties Ketamine can transiently worsen psychosis in some mental illness Halop...

Author: Don Stader, MD Educational Pearls:   Three options for a blister in partial thickness burns:  do nothing, unroof it, or poke a hole in it Recent study suggest that aspirating the blister may be more effective in regards to wound healing The overlying skin acts as a bio-band-aid and patients recover slightly faster References: Ro HS, Shin JY, Sabbagh MD, Roh SG, Chang SC, Lee NH. Effectiven...

Author: Don Stader, MD Educational Pearls:   Intravenous Tylenol currently is many times more expensive than oral Single ED study comparing the two has methodology flaws and there is a lack of additional evidence to support intravenous over oral formulations solely for pain control Oral Tylenol appears to be at least equally efficacious, though with a slightly slower onset of action   References:...

Author: Don Stader, MD Educational Pearls:   Recent study has revealed that infant walkers are more harmful than helpful Infant walkers can also delay motor function The American Academy of Pediatrics calls for a ban on walkers as they are a preventable cause of injury   References: Siegel AC, Burton RV. (1999).Effects of baby walkers on motor and mental development in human infants. Journal of De...

Author: Sam Killian, MD Educational Pearls:   Recent news articles are showing an increase in injuries related to riding electric scooters Year-to-year, scooter injuries have increased as high as three to four times More definitive evidence still to come Editor's note: don't follow birdgraveyard on instagram References: https://www.washingtonpost.com/business/economy/scooter-use-is-rising-in-major...

Author: Mark Hinton, MD Educational Pearls:   Meniscus lock can occur with a tear leading to inability to extend the knee Treatment can include an intra-articular joint block followed by straightening Medial meniscus injuries are more common   References: Allum RL, Jones JR. The locked knee. Injury. 1986 Jul;17(4):256-8. PubMed PMID: 3770920. Critchley IJ, Bracey DJ. The acutely locked knee--is a...

Educational Pearls: RSI includes induction agent (sedative) and a paralytic Succinylcholine is a depolarizing paralytic of rapid onset and short duration with contraindications in hyperkalemic states and muscular dystrophy Rocuronium and vecuronium are longer acting, non-depolarizing paralytic, more commonly Common induction agents are etomidate and ketamine Ketamine can be particularly beneficial...

Author: Gretchen Hinson, MD Educational Pearls: Diagnosis can be difficult and often delayed Asymmetric breath sounds, choking, stridor may be present, but children also present asymptomatically Peak incidence around one to two years of age Hot dogs, nuts, popcorn – round and smooth objects are most commonly aspirated References: Green SS. Ingested and Aspirated Foreign Bodies. Pediatr Rev. 2015 O...

Author: Dylan Luyten, MD Educational Pearls:   Extracorporeal membrane oxygenation (ECMO) is similar to bypass ECMO is being utilized routinely at some centers and even prehospital in cardiac arrest There are two general types of ECMO: Venovenous (VV-ECMO) is useful when the patient cannot oxygenate but has adequate heart function. Venoarterial (VA-ECMO) is more like typical bypass and can be used...

Author: Michael Hunt, MD Educational Pearls: Alcohol and gallstones are most common causes of pancreatitis Diagnosis is not simply based on lipase alone - must have at least two the the three criteria: Elevated lipase (greater than 3x upper limit of reference range) Typical pain (epigastric pain, radiating to back, etc.) Radiographic findings suggestive of pancreatitis (CT, MRI, US) BISAP criteria...

Author: Erik Verzemnieks, MD Educational Pearls: Recent study provides at least some evidence to help predict antibiotic failure for cellulitis, which is not necessarily straight forward Intuitive risk factors such as recent cellulitis, chronic ulcers, history of MRSA are associated with antibiotic treatment failure Oddly, tachypnea at triage was associated with the highest odds ratio for treatmen...

Author: Aaron Lessen, MD Educational Pearls:   Injuries from penetrating pharyngeal trauma  are often subtle on examination in children Potentially serious complications including carotid artery injury, mediastinitis from spreading infection, or airway compromise from hematoma formation Imaging choice is typically CTA to assess for vascular injuries These injuries may require antibiotics   Referen...

Author: Rachel Brady, MD Educational Pearls: Hypercalcemia of malignancy: Hypercalcemia of malignancy can present with lethargy, muscle weakness, hyperreflexia, altered mental status, cardiac dysrhythmias, and even cardiac arrest. Treatment is based both on calcium level and symptoms Intravenous rehydration is first line treatment Other options include steroids, bisphosphonates and calcitonin.  Tu...

Author: Aaron Lessen, MD Educational Pearls:   In patients without indications for aspirin, three recent studies looked at prevention of several end points in the elderly These showed no benefit in preventing cardiovascular events (stroke, MI, hear failure), disability, or death in elderly These studies also demonstrated higher mortality and increased bleeding risk in patients who were taking aspi...

Author: Katie Sprinkle, MD Educational Pearls: Medication Assisted Treatment (MAT) is the treatment of addiction with medications, commonly used for opioid use disorders A long held belief is MAT simply replaces one addiction for another, which is patently false MAT is one of the most affective methods to treat a patient with opioid addiction Unfortunately, outdated requirements for prescribers al...

  Author: Peter Bakes, MD Educational Pearls:   Important historical information to elicit is the birth history, feeding habits, stooling habits, associated symptoms, presence of bile, and presence of trauma. Volvulus is a common etiology of intestinal obstruction and is often due to malrotation in utero.   Editor's note: get an upper GI series if there is any bilious vomiting in a neonate. Any ti...

Author: Jared Scott, MD Educational Pearls: Interest started as it was noticed soldiers who had wounds infected with maggots had better outcomes than those without maggots Studies have shown that wound care with maggots is essentially equivalent to traditional therapy with oxygen, antibiotics, and debridement Maggots debride the wound with proteolytic enzymes, sterilize the wound, and stimulate wo...

Author: Peter Bakes, MD Educational Pearls:   Necrotizing fasciitis is an infection of the deep soft tissues with destruction of the muscle fascia and overlying fat Think of it if pain is out of proportion to your exam Polymicrobial and Clostridium species typically cause condition in susceptible individuals (immunocompromised, diabetics, obese, penetrating injury) Group A strep typically is less...

Author: Gretchen Hinson, MD Educational Pearls:   Reasonable approach of haloperidol 10 mg IM (or 5 mg IV) for pain relief in opioid-dependent patients; can repeat once Chronic opioid use results in hyperalgesia and a narrow therapeutic window in the long-term so alternatives are essential Consider the risk of QTc prolongation with haloperidol, particularly if the patient is on other drugs that ma...