Emergency Medical Minute

Educational Pearls:   BRUE (Brief Resolved Unexplained Event) replaces what was previously called ALTE BRUE describes an event in a child less than one year of age with one or more of the following: cyanosis or pallor absent, decreased, or irregular breathing decreased or increased tone altered responsiveness These must be sudden, brief, and now resolved and without an alternative explanation afte...

Author:  Aaron Lessen, MD Educational Pearls:   5-year follow up study on antibiotic treatment for uncomplicated appendicitis showed 39.1% recurrence rate requiring appendectomy by 5 years Nearly 60% chance then of preventing an appendectomy by using antibiotics only for uncomplicated appendicitis   Editor's note: not surprisingly, complications were much higher in the group receiving surgery, whi...

Author:  Don Stader, MD Educational Pearls:   Fluoroquinolones can cause connective tissue disruption leading not only to tendon rupture but also aortic dissection Retrospective study from Taiwan showed over a 2x higher rate of dissection when exposed to fluoroquinolones (1.6% vs 0.6%) Remember to think about aortic dissection when you have a patient with chest pain that travels and/or involves ne...

Author:  Kasey Champion, MD Educational Pearls:   Transgender populations are frequent victims of discrimination in healthcare Ask transgender patients what their preferred pronoun is It is sometimes important to ask about transition status (i.e. on hormones, surgery)     References: Chisolm-Straker M, Willging C, Daul AD, McNamara S, Sante SC, Shattuck DG 2nd, Crandall CS. Transgender and Gender-...

Author:  John Winkler, MD Educational Pearls: Probiotics are bacteria that are ingested to promote gut health but recent research casts doubt on their effectiveness. Recent study suggests that most probiotics that are ingested are killed by stomach acid. Those that remain are not very healthy and are outcompeted by the normal gut flora. Probiotics should not be given as a one-size-fits-all treatme...

Author:  Don Stader, MD Educational Pearls:   Recent study suggests we may not need to drain uncomplicated peritonsillar abscesses Patients who received medical therapy alone had no difference in complications and failure compared to those who received surgical drainage plus medical therapy Medical therapy in study was ceftriaxone, clindamycin, and dexamethasone Medical therapy was also associated...

Author:  Sam Killian, MD Educational Pearls:   Two high quality randomized control trials published in 2018 demonstrated no difference in mortality or neurologic outcomes when using a supraglottic airway compared to endotracheal intubation in out of hospital cardiac arrest These two trials enrolled over a combined 12000 patients Supraglottic airways have a higher success rate than intubations   Re...

Author:  Ryan Circh, MD Educational Pearls:   A "shoulder separation" is when the clavicle separates from the scapula - also referred to as an acromio-clavicular (AC) separation Diagnosis is clinical: pain over AC joint, pain with adduction, and difficulty raising harm past horizontal Early range of motion can be critical for recovery     References: Lemos MJ. The evaluation and treatment of the i...

Author:  Sam Killian, MD Educational Pearls: MRI machines can generate enough heat from the radiofrequency to cause thermal burns   Patients with EKG stickers, medication patches, clothing impregnated with metallic ions, etc., can all increase risk of burns Even skin-to-skin contact within the patient can cause a misinterpretation from the software and increased energy, leading to burn   Reference...

Author:  Ryan Circh, MD Educational Pearls:   Review of 25 randomized control trials encompassing 16,037 acutely ill hospitalized patients Patients given oxygen with saturations > 94% on room air were found to have associated increased mortality in-hospital, at 30-days, and at long-term follow up It may seem intuitive, but do not give oxygen to patients that do not need it   References: Chu DK, et...

Author:  Sam Killian, MD Educational Pearls:   Patients may have certain fears or expectations about the flu based on hearsay and other less reliable sources Taking extra time explaining the risks of the flu may help base these expectations more in reality This includes providing good return precautions and acknowledging that the disease can still be unpredictable    

Author:  Michael Hunt, MD Educational Pearls:   Use the mnemonic NOT RECLUSE to rule out a brown recluse spider bite: Numerous bites (recluse spiders will bite once) Occurence (recluse bites between April- October) Timing (recluse spiders are… get this…  reclusive) Red (recluse bites are white/pale) Elevated (recluse bites are flat) Chronic (recluse bites are acute) Large (recluse wounds are small...

Author:  Nick Tsipis, MD Educational Pearls:   Persistent fever or positive blood cultures should raise suspicion for endocarditis Patients with recent dental procedures, recent cardiac surgeries are at risk, or who inject drugs are at higher risk Physical exam findings may include fever with a new murmur, Janeway lesions, Osler nodes, and/or splinter hemorrhages   References: Long B, Koyfman A. I...

Educational Pearls:   Blood concentrations over 0.4 mg/dL  is associated with respiratory depression and possible death in alcohol naive patients Alcohol overdose accounts to 2,200 deaths per year Don't forget about checking for hypoglycemia in severe alcohol intoxication Consider ketamine for agitation to prevent further respiratory depression   Editor's note: check out our podcast on ketamine fo...

Author:  Jared Scott, MD Educational Pearls:   Blood at urethral meatus in trauma can be a sign of bladder/urethral injury Blind placement of a Foley catheter can make an undiagnosed urethral injury worse Urethral injury is evaluated using a retrograde urethrogram (RUG) If urethra is confirmed to be intact, Foley catheter can be placed to allow additional tests   References: Avery, L. (2012). Imag...

Author:  Sue Chilton, MD Educational Pearls:   An unusual cause of leg pain that can mimic sciatica/claudication Predominantly occurring in high endurance athletes, particularly cyclists and runners More common in men Check supine ABIs 1 minute after activity in the ED: a value < 0.5 is 80% sensitive   References: Mansour A, Murney S, Jordan K, Laperna L. Endofibrosis: an unusual cause of leg pain...

Author:  Gretchen Hinson, MD Educational Pearls:   Legionnaires disease refers to a severe pneumonia caused by Legionella pneumophilia and occurs typically at the extremes of age Associated gastrointestinal symptoms (nausea/vomiting/diarrhea) may be present Hyponatremia is a common laboratory finding Legionella urinary antigen can be a convenient test to identify the infection Treatment is with fl...

Author:  Don Stader, MD Educational Pearls:   8014 patients with out-of-hospital cardiac arrest randomized to epinephrine vs placebo 30-day survival was not dramatically better between groups (3.2%in the epinephrine group and 2.4% in the placebo group) Functional neurological outcome was nearly identical at 2.2% and 1.9% of patients Adds to literature that epinephrine provides little important ben...

Author:  Jared Scott, MD Educational Pearls:   EKG changes do not necessarily correlate to degree of hyperkalemia Traditional progression through peaked T-waves, flattened p-waves, QRS widening, and then sine-waves before asystole     References Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721–729.

Author:  Erik Verzemnieks, MD Educational Pearls:   In the panic of a precipitous ED delivery, remember: Warm. Dry. Stim.  It will solve most of your problems in most scenarios Start compressions if heart rate is less than 60 Put the pulse ox on the right hand - it may make a difference as it is preductal   Editor's note: detecting a heart rate can be tough in a newborn - you can feel the umbilica...

Author: Michael Hunt, MD Educational Pearls: Here is a list of some very toxic natural substances:     #5: Tetrodotoxin: Found in pufferfish and other aquatic species #4: Ricin: made from castor beans #3: Mercury: natural element absorbable through skin and gloves #2: Batrachotoxin: found on poison dart frogs #1: Botulinum toxin: produced by Clostridium botulinum and causes a descending paralysis...

Author: Aaron Lessen, MD Educational Pearls:   Non-blinded randomized study assessing 30-day mortality benefit from plasma-first resuscitation in patients at risk hemorrhagic shock Study involved aeromedical transport of trauma patients 30-day mortality 23.2 % in intervention group vs. 33.0% in standard care group   Editor's note: a similar study published in Lancet at the same time showed no mort...

Podcast # 367: Digital Necrosis after Epinephrine Drip Author: Jared Scott, MD. Educational Pearls:   Make sure to monitor for limb ischemia in all patients on vasopressors Good reminder that vasopressors are not risk free - use them only on patients that need them!   References Daroca-Pérez, R., & Carrascosa, M. F. . Digital necrosis: a potential risk of high-dose norepinephrine. Therapeutic Adva...

Podcast # 366: Ehlers Danlos Author: Gretchen Hinson, MD. Educational Pearls:   Heritable mutation in collagen synthesis and expression commonly resulting in joint hyperextension and skin elasticity. Vascular type can result in aneurysm formation and rupture in young patients. Patients are also at risk for spontaneous bowel rupture. Pregnant women can present with uterine rupture.   References Bye...

Author: Erik Verzemnieks, MD Educational Pearls:   Single study in Japan demonstrated possible effectiveness of renal colic trigger point Patients had injection at the area of maximal tenderness on palpation of the flank Compared to a muscle relaxer, injection of local anesthetic at the trigger point had faster time to pain relief and fewer rescue therapies  References Iguchi, M et al. Randomized...