Emergency Medical Minute

Author: Jared Scott, MD Educational Pearls: Data is mixed, but some studies show 1-2% of pregnancies are ectopic. Risk factors for ectopic pregnancies include: pelvic inflammatory disease, prior ectopic pregnancy, prior abdominal surgery, prior abortion, advanced maternal age, IUD, tubal blockage, and smoking (including spouse). Greatest risk factor is a prior ectopic pregnancy, which carries a 17...

Author: Chris Holmes, MD Educational Pearls: Symptoms commonly seen with mononucleosis are palatal petechiae, posterior cervical lymphadenopathy, inguinal/axillary lymphadenopathy, splenomegaly, and/or atypical lymphocytes > 10% on CBC. Among these, posterior cervical lymphadenopathy and atypical lymphocytes > 10% were the most sensitive (sensitivities of 0.64 and 0.66 respectively). References We...

Author: John Winkler, MD Educational Pearls: Singed nasal hairs, soot around mouth, hoarse voice, drooling, and burns to head/face are signs suggestive of inhalation injury. Early intubation is critical for these patients as the airway changes rapidly. With inhalation injuries, the upper airway is burned while the lower airway is damaged by inhaled chemicals in the soot and can cause ARDS. Carbon...

Author: Dylan Luyten, MD Educational Pearls:   Most important questions to answer with low potassium are 1. What are their symptoms? 2. Can they take potassium by mouth? Oral repletion is faster, cheaper, and more effective than IV repletion. Give IV potassium when patients have K < 2.5 mmol/L or present with arrhythmias and/or characteristic EKG changes (flattened T waves). Most patients who are...

Author: Peter Bakes, M.D. Educational Pearls:   Epidural hematomas have a characteristic convex appearance on CT while a subdural hematoma will have a concave appearance. Indications for operative intervention for subdural hematoma may include: >5 mm midline shift, over 10 mm in thickness, comatose with ICP >20, or patient neurologic deterioration.   References Bullock, M. R. et. al. . Surgical ma...

Author: Dylan Luyten, MD Educational Pearls:   Resuscitative thoracotomies are most commonly used for treatment of cardiac tamponade and to selectively perfuse the brain and heart in setting of hemorrhage control. Resuscitative thoracotomies are indicated in patients with penetrating injuries who lose vitals in the ED or those who had vitals within the last 10 minutes. Do not perform resuscitative...

Author: Michael Hunt, MD Educational Pearls:   Studies have shown that patients with decreasing GCS scores have worse outcomes, however GCS of 4 has worse outcome than GCS 3. Alternative scoring system is the GCS-P score which is GCS score - number of non-reactive pupils. GCS3 50% mortality 70% poor outcome at 6 months; GCS-P of 1 had mortality 74% and poor outcome at about 90% at 6 months. GCS-P...

Author: Nick Hatch, MD Educational Pearls:   Recent study argues that CHF patients receiving furosemide within 60 minutes of arrival had a lower in-hospital mortality than those receiving it after (2.3% vs. 6.0%, p=0.002). Flaw in study is that there were significant baseline differences between groups.   References: Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitaliz...

Author: Nick Hatch, MD Educational Pearls:   The sodium-glucose cotransporter in the gut is essential for rehydration. Oral rehydration therapies require an equimolar concentration of glucose and sodium to be effective. ORT has saved millions of lives globally. Consider using ORT in patients with dehydration. Especially useful in resource limited settings.   References: Victora CG, Bryce J, Fontai...

Author: Nick Hatch, MD Educational Pearls:   Behcet Disease is an autoimmune disease that can affect any organ system. Typical symptoms include recurrent oral and genital ulcers, but more concerning features include skin rashes, ocular problems, and strokes. Patients with Behcet disease with hypotension should have low threshold for giving steroids.   References: Arlt W, Allolio B. Adrenal insuffi...

Author: Dylan Luyten , MD Educational Pearls:   Rare autosomal dominant condition that is often misdiagnosed as a psychiatric illness. Presents as profound muscle weakness with frank paralysis that is often precipitated by vigorous exercise, high carb diet, high sodium load, or by high temperatures. Supplemental potassium can rapidly reverse symptoms. Important to rule out thyrotoxicosis (get a TS...

Author: Sam Killian, MD Educational Pearls:   Insufficient sleep and disrupted circadian rhythms are a major health problem today   Millions of dollars, thousands of deaths, and millions of  injuries are related to sleep deprivation every year 56 billion dollars - 24,000 deaths - 2.5 million disabiling injuries related to a sleep-type deprivation Exxon valdez, challanger, chyrnobel linked to sleep...

Author: Don Stader, MD Educational Pearls:   The use of fecal occult blood tests is falling out of favor in emergency departments These tests have strong evidence suggesting their efficacy in colon cancer screening but clinical significance in ED is limited They have relatively high false positive and false negative rates Small/microscopic bleeding are often not clinically significant in the ED bu...

Author: Michael Hunt, MD Educational Pearls: Valley fever is a fungal infection known as Coccidiomycosis that can present with vague symptoms like cough, fever, myalgias. A thorough history is critical to the diagnosis. Disease is localized to  the Southwestern US (California, New Mexico, Arizona, Nevada, Utah) and parts of Central/South America. Disease is caused by inhaling fungal spores which d...

Author: Sam Killian, MD Educational Pearls: Being exposed to E-cigarette vapor may increase risk of pneumonia. Recent study has shown e-cigarette vapor increases quantities of Platelet-activating-receptor factor in epithelial cells, which may aid pneumococcal bacteria in entering pneumocytes. References: Miyashita L, et al. (2018). E-cigarette vapour enhances pneumococcal adherence to airway epith...

Author: Rachel Beham, PharmD Educational Pearls: Some synthetic cannabinoids have been contaminated with Brodifacoum. Brodifacoum is a Vitamin K antagonist and can present with a severe coagulopathy. Brodifacoum is commonly known as "superwarfarin" and has a very long half life of 120+ days. Check PT/INR in patients with a bleeding diathesis in setting of synthetic cannabinoid use. Treatment is ac...

Author: Jared Scott, M.D. Educational Pearls: Cardiac myocytes and vascular smooth muscle are dependent on an intracellular calcium influx for contraction. Pancreatic beta cells rely on calcium to release insulin. Calcium channel blockers will decrease cardiac contractility and heart rate, but will also cause vascular smooth muscle relaxation with a subsequent decrease in systemic vascular resista...

Author: Nick Hatch, M.D. Educational Pearls:   Methemoglobinemia is when the iron in hemoglobin is in the Fe3+ (ferric) state rather than the normal Fe2+  (ferrous) state. Methemoglobin cannot release oxygen at the tissues. Symptoms include cyanosis, headache, tachycardia, dyspnea, and lethargy. Suspect in setting of hypoxia that does not improve with oxygenation, and clinical cyanosis with a norm...

Author: Jared Scott, M.D. Educational Pearls:   Recent study compared Compazine with Benadryl vs. Dilaudid for acute migraine management in the ED. Compazine + Benadryl demonstrated migraine relief in 60% of patients compared to the 31% of patients who were relieved with Dilaudid. Compazine + Benadryl is a superior migraine treatment than Dilaudid.   References: Friedman BW, et. al. (2017). Random...

Author: Don Stader, M.D. Educational Pearls:   Pulmonary embolism is one of the leading causes of maternal mortality. There is disagreement among different medical societies about the value of D-dimer as a screening modality. If you use it, consider the rational D-dimer approach whereby you add 250 to your cut-off for every trimester. A useful screening modality is an ultrasound of bilateral lower...

Author: Aaron Lessen, MD Educational Pearls:   Shockable rhythms like V-fib or V-tach have a better prognosis than patients with PEA or asystole. Recent study has shown an initial electrical frequency in PEA between 10-24/min had worse outcomes than PEA with initial rhythm over 60/min. Patients with an initial electrical frequency in PEA over 60/min did just as well as patients with shockable rhyt...

Author: Erik Verzemnieks, M.D.  Educational Pearls: ●  Common causes of nystagmus: Congenital disorders, CNS diseases (MS, CVA), Intoxication ●  Drugs associated (ETOH, Ketamine, PCP, SSRI, MDMA, Lithium, Phenytoin, Barbiturates) ●  If a patient has nystagmus and is intoxicated, consider other drugs and etiologies as potential sources References: Alpert JN. (1978). Downbeat nystagmus due to antico...

Author: John Winkler, M.D. Educational Pearls: ●  Lower mechanisms of injury have a lower chance of an associated fracture or major ligament injury ●  One major concern is having a fracture fragment in the joint (can lead to chronic arthritic pain) ●  Evaluation should involve checking the neurovascular status of the arm and reduce the fracture as soon as possible. Immobilize arm in a sling and co...

Author: Michael Hunt, M.D. Educational Pearls:   1% of patients presenting to ED with alcohol intoxication end up going to the ICU Most common critical illnesses were acute hypoxic respiratory failure, sepsis, and intracranial hemorrhage Predictive markers: Vital abnormalities (hypoxia, tachycardic, tachypneic, hypothermic, hyperthermia, hypoglycemia) and patients receiving parenteral sedatives ha...

  Author: Dr. Karen Woolf, MD Educational Pearls: Anatomy : base of skull to posterior mediastinum, anteriorly bounded by middle layer of deep cervical fascia and posteriorly by the deep layer, communicates to lateral pharyngeal space bounded by carotid sheath. Lymph node chains draining nasopharynx, sinuses, middle ear, etc. run through it. Epidemiology & Microbiology: most common kids 2-4, (neon...