Emergency Medical Minute

Author: Peter Bakes, MD Educational Pearls:   Pericarditis, LBBB, LVH and left ventricular aneurysms can all present with ST elevation. Ventricular aneurysm will present days after a cardiac event with ST elevation and Q waves in the affected leads. Ventricular aneurysms may cause papillary muscle dysfunction with a resultant holosystolic murmur and even heart failure.   References Victor F. Froel...

Educational Pearls:   Recent study has shown adjunctive ketamine can be useful in setting of alcohol withdrawal. Ketamine was associated with a decrease in the amount of benzodiazepines needed, likelihood of intubation, and a decrease in ICU length of stay by 3 days. For patients with benzodiazepine resistance, ketamine was shown to have symptom relief in an hour and decreased rate of benzodiazepi...

Author: John Winkler, MD Educational Pearls:   Tall flowering plant with phototoxic sap Direct skin contact with the sap can cause the skin to become photosensitive Severe blisters and even burns can result   References Diebel, Matthew (18 June 2018). "Giant Hogweed, a Plant That Can Cause Burns and Blindness, Found in Virginia". USA Today .  

Author: Peter Bakes, MD Educational Pearls:   Important to find out if patients mean dysequilibrium, lightheadedness, or vertigo when patients say they are "dizzy." Differentiate central vs. peripheral vertigo Central vertigo typically present with bulbar syndromes (difficulty swallowing, facial nerve palsy) and cerebellar symptoms (ataxia). Peripheral vertigo typically present with sudden onset v...

Author: Dylan Luyten, MD. Educational Pearls:   Dangerous causes of back pain: AAA, cauda equina syndrome, epidural abscess. Young person with back pain needs to be evaluated for injection drug use (major risk factor). Patient with focal neurologic deficits (FND) require an MRI.  Patients without FND can be screened with ESR and CRP. An ESR < 20 & CRP < 1 can effectively rule out epidural abscess...

Author: Sam Killian, MD. Educational Pearls:   Computer interpretation has a very good negative predictive value of a normal EKG (99%). Of 222 interpreted as "normal," 13 were deemed to have some abnormality by a cardiologist in a recent study. Those 13 EKG's were read by 2 ER docs, and only 1 missed interpretation warranted a move from triage to a bed.   References Katie E. Hughes KE., Scott M. L...

Author: Erik Verzemnieks, MD Educational Pearls:   Otic (ear) specific antibiotic drops can be expensive Opthalmic (eye) versions are basically identical and can be used as an affordable substitute as many are on the $4 drug lists But don't do the reverse (don't use ear drops on the eye) Use caution when administering aminoglycoside if tympanic membrane rupture is present   References https://tgtf...

Author: Michael Hunt, MD Educational Pearls:   Toxicity happens from local anesthetics being given too fast, too much, or in the unintended spot Systemic toxicity manifests first with neurologic symptoms like circumoral numbness, tinnitus, blurred vision, nausea, and even seizures. Severe toxicity can then progress to arrhythmias and cardiac arrest. Maximum doses of lidocaine: 4 mg/kg; and with ep...

Author: Don Stader, MD. Educational Pearls:   A baby can be born dependent on opioids but not addicted to them. Opioid addiction (Opioid Use Disorder) is a disease of mature brains and is characterized by compulsive drug use despite adverse consequences. Opioid addiction is a disease that affects the reward center of the brain Pregnant patients struggling with addiction do better when started on b...

Author: Aaron Lessen, MD Educational Pearls:   Re-emerging STI. Progresses through distinct phases if untreated: Primary syphilis: frequently overlooked because initial chancre is painless. Secondary syphilis: viral syndrome, rash on trunk, palms, and soles. Latent syphilis: asymptomatic period, lasting 5-20 years. Tertiary syphilis: includes neurosyphilis (dementia, encephalitis, etc.) and cardio...

Author: Sam Killian, MD Educational Pearls:   Hematometra: uterus filled with blood due to obstruction of outflow tract. Most commonly a result congenital abnormalities (imperforate hymen, transverse vaginal septum, etc.) but can be acquired due to cervical stenosis, intrauterine adhesions, neoplasms, and post-surgical scarring. Symptoms include: pain, abnormal bleeding, enlarged uterus Diagnosis:...

Author: Sam Killian, MD Educational Pearls:   Japan recently approved baloxavir marboxil (Xofluza), which may potentially "kill" Flu A/B within 24 hours Recent RCT trial showed superiority over oseltamavir (Tamiflu) in cessation of viral shedding (24 vs 72 hours) Compared to placebo, superior in time to symptom resolution (53.7 vs 80.7  hours) Administered as single dose Yet to be considered for F...

Podcast #352: TXA for Epistaxis Author:  Chris Holmes, M.D. Educational Pearls:   TXA: tranexamic acid; used in control of bleeding in major trauma, postpartum hemorrhage, etc. In study of 216 patients with epistaxis, TXA placed on a pledget was compared to anterior cotton nasal packing. The TXA group had faster time to bleeding control, quicker time to discharge, better patient satisfaction, and...

Author:  Pete Bakes, MD Educational Pearls:   AICD: Automated Implantable Cardioverter-Defibrillator. Can be placed for secondary prevention of cardiac arrest (i.e. history of cardiac arrest not from reversible cause). Also indications for primary prevention: EF 35% or less; ventricular tachycardia with underlying structural heart disease; Brugada; genetic-induced prolonged QT-syndromes.   Referen...

Author: Nick Hatch, MD. Educational Pearls:   A common concern using vasopressors is the risk of digital and mesenteric ischemia. The absolute risk of digital ischemia and/or mesenteric ischemia is pretty low. Norepinephrine at its highest doses carries a 5% digital ischemia rate and a 2% mesenteric ischemia rate. The studies demonstrating this complication were predominately patients with pre-exi...

Author: Sue Chilton, MD Educational Pearls:   Triad of fat emboli syndrome is a petechial rash, AMS, and respiratory distress. Petechiae usually start in the axilla. 90% of patients with long bone fractures will shed fat. May see ground-glass opacities on imaging, but perfusion defects will not be seen on CTA or V/Q scan Patients with a PFO can have cerebral involvement.   References Newbigin K, S...

Author: Don Stader, MD Educational Pearls:   Steakhouse syndrome is an impacted esophageal food bolus. Occurs because they have an esophageal stricture (schatzki ring, scarring, esophagitis). Classic treatments have consisted of effervescents, glucagon, and/or sublingual nitroglycerin (NTG). Recent case series has shown oral 400mcg tablet of NTG dissolved in 10cc tap water was 100% successful. Com...

  Author: Sam Killian, MD Educational Pearls:   Recent study examining fasting and adverse events during procedural sedation found no association between fasting duration and any type of adverse event. Of the 6,183 children in the study, about 6 vomited during the procedure, and about 300 vomited recently after the procedure, and there were no episodes of aspiration.   References Bhatt, M, et al....

Author: Chris Holmes, MD Educational Pearls:   There is a risk of cerebral edema in pediatrics with DKA if over resuscitated. Recent study comparing normal saline vs. ½ normal saline showed no difference in rates of cerebral edema regardless of rate of infusion. Recommend sticking with a fluid resuscitation protocol you are familiar with (i.e., 2 rounds of 10cc/kg bolus of NS).   References Glaser...

Author: Sue Chilton, MD Educational Pearls:   IV drug use and spinal procedures are major risk factors. Classic triad of back pain, focal neurological deficit and fever. However, presence of fever is highly variable. Neurologic deficits may not present until later, but then they can have a rapid progression of neurological decline. MRSA is most common organism, but GNR and MSSA are also possible....

Author: Aaron Lessen, MD. Educational Pearls:   When foley is stuck, balloon may not have deflated. Make sure balloon is not in the urethra, which can block drainage. Cut off the port as it may be obstructed. If still not draining, pass guide wire through port to unclog catheter. Other techniques have been described using mineral oil to dissolve, rupturing the balloon through over-inflation, and t...

Educational Pearls:   Snake bites commonly occur between April and October. Rattlesnake bites are the most common. Venom contains proteins/enzymes that cause local inflammation, coagulopathy, and systemic effects (hypotension, angioedema, renal failure, etc.) along with neurotoxins may cause fasciculations, ptosis, drooling, or hyporeflexia. Management: Mark site for swelling. Monitor progression....

Author: Jared Scott, MD Educational Pearls: Scombroid is a type of food poisoning associated with dark fish (i.e. tuna, salmon, mackerel) that mimics anaphylaxis. Occurs through conversion of histidine to histamine by bacteria in the fish. Symptoms include flushing, lips swelling, nausea, diarrhea in setting of recent fish consumption. Treat with antihistamines.   References Ridolo E, Martignago I...

Author:   Rachel Beham, PharmD Educational Pearls: Tenecteplase is more specific for fibrin and has a longer half-life than alteplase. In setting of ischemic stroke, tenecteplase before thrombectomy was associated with a statistically higher incidence of reperfusion and better functional outcome than alteplase. References Bruce C.V. Campbell B et al (2018). Tenecteplase versus Alteplase before Thr...

Author: Chris Holmes, MD Educational Pearls:   Epidemiology: 80% male, ages 1-4 at greatest risk, African-American > Caucasian. Freshwater and ocean water may have more bacteria than pool water. Salt water is hyperosmolar, which theoretically increases risk of pulmonary edema. Greatest physiologic insult is from hypoxia secondary to fluid aspiration or laryngeal spasm. Patient survival is related...