Emergency Medical Minute

Author: Rachael Duncan, PharmD Educational Pearls A NEJM study report in July 2016 discussed a situation in New York during which 30 people became "zombie-like" after ingesting synthetic cannabinoids (aka "Spice). The ER managed to coordinate with the CDC to evaluate  blood samples from 18 patients who were transported to the hospital. Of those who went to the ER, the mean age was 36.8, many  of t...

Author: Sam Killian, M.D. Educational Pearls Traditionally, UTI diagnosis has been dependent on urine culture, urinalysis and clinical symptoms. But a recent study casts some doubt on the utility of urine cultures. A study in the Journal of Clinical Microbiology did urine cultures and E. coli PCR in 220 women with UTI symptoms and 86 women without UTI symptoms. In the symptomatic women, 67% had po...

Author: Michael Hunt, M.D. Educational Pearls Rhabdomyolysis is caused by the destruction of skeletal muscle that leads to the release of myoglobin, which causes renal failure. It presents with pain and weakness in the affected muscle, as well as dark urine. Diagnosis is made with creatinine kinase levels It can happen to extreme athletes after competition, but the most common presentation is in p...

Author: Sam Killian, M.D. Educational Pearls Transient global amnesia is a paroxysmal, transient memory issue. Remote and immediate memory is preserved, but new memories cannot be made. Patients will have a normal neurological exam and usually no other complaints. The episode will last less than 24 hours, but they usually resolve after 1-2 hours. This is relatively common. It happens in 5/100000 p...

Author: John Winkler, M.D.  Educational Pearls Normally, the parathyroid is the master regulator of serum Ca levels. It secretes PTH, which stimulates calcium uptake from the bone and gut. Causes of hypercalcemia include: parathyroid tumor, lytic bone lesions (multiple myeloma), breast cancer, renal injury, and some lung cancers. Hypercalcemia can lead to poor bone quality and pathological fractur...

  Author: Nick Hatch, M.D. Educational Pearls The Cincinnati Stroke Scale uses 3 measures to screen for ischemic stroke. The measures are: facial asymmetry, speech quality and arm drift. This scale is used commonly in EMS systems as a screening tool. Studies show that having one out of the 3 elements correlates with a 72% chance of having an ischemic stroke, while having all 3 of the elements corr...

Author: Dave Rosenberg, M.D. Educational Pearls DKA commonly causes hyperkalemia, leading to peaked T-waves on ECG. However, DKA causes hypokalemia at the same time. In DKA, glucose cannot be taken into the cells. This signals the body to create and use acidic ketones for energy. This leads to acidosis. To compensate for increased acid, H ions are pumped into cells. To maintain electroneutrality,...

Author: Dylan Luyten, M.D. Educational Pearls Cannabinoid Hyperemesis syndrome is a relatively new diagnosis that presents with vomiting and abdominal pain without a clear etiology in the setting of daily marijuana use. The pathophysiology is not well-understood well, but may involve cannabinoid receptors in the gut. Treatment is abstinence from marijuana, fluids, dextrose, and antiemetics (haldol...

Author: Peter Bakes, M.D. Educational Pearls Chronic diarrhea is defined as 3 or more loose, watery stools lasting more than 2-3 weeks. Look for clues in the history, including  travel (could suggest infectious etiology), antibiotic use (could suggest C. Diff), and family history. Irritable Bowel Disease (Crohn's/Ulcerative Colitis) is an autoimmune disorder that affects 1.3 million Americans and...

Author: Aaron Lessen, M.D. Educational Pearls Treatment "bundles" are a popular approach to the rapid resuscitation of septic patients. A recent study in New York, where sepsis bundles are mandatory, sought to figure out which aspects of the bundle had impacts on mortality. In a study of 40,000 septic patients, the study found that early antibiotics were associated with better outcomes, while earl...

Author: Don Stader, M.D. Educational Pearls While we usually associate the coronary vasculature with STEMIs, there are other pathologies that can affect the heart's blood supply. Kounis syndrome: an allergic vasospasm of the coronary arteries. This can happen post anaphylaxis or be caused by a stent allergy. It is best treated with aggressive management of the allergic reaction. Kawasaki disease:...

Author: Aaron Lessen, M.D.  Educational Pearls While C. difficile infections are generally thought of as nosocomial, there is a subset of patients who acquire the infection in the community. One recent study showed that about 10% of patients presenting to the ED with diarrhea and without vomiting had a C. diff infection. Another study found risk factors for community-acquired C. diff included rece...

Author: Erik Verzemneicks, M.D. Educational Pearls 1/600 flights has an on-board request for medical assistance. Most common complaints on board include: syncope, respiratory complaints, and GI complaints. Most of the time, these are exacerbations of underlying chronic conditions. Except for situations involving gross negligence, the Aviation Assistance Act protects providers from legal action as...

Author:  John Winkler, M.D. Educational Pearls Photokeratitis is a UV burn of the sclera and cornea, which can cause blindness. UV light causes eyelid swelling with diffuse scarring of the eye (widespread, punctate uptake of fluorescein dye). While this can eventually heal, it is incredibly painful. Snow reflects light underneath sunglasses, so wrap-around goggles are the best form of prevention....

Author: Dave Rosenberg, M.D. Educational Pearls EKG changes that can be seen in DKA include ST elevation and peaked T-waves secondary to derangements in K levels. In DKA,  serum K is high, but total body K is low, which can cause said EKG abnormalities. Many things cause ST elevation besides MI, so think beyond STEMI. When someone in in DKA, think about the "Three I's" for underlying cause: (not t...

Author: John Winkler, M.D. Dr. Winkler shares his knowledge of wilderness medicine and provides insight on how to prevent and treat conditions such as hypothermia, frostbite and sun blindness. More importantly, he gives us tips on how to stay safe while doing our favorite wintertime activities!

Podcast #281: Intracranial Hemorrhage Treatment Author: Don Stader, M.D. Educational Pearls Types of traumatic bleeds include subdural, epidural, and subarachnoid. Treatment for a traumatic bleed includes maintenance of systolic BP above 120 and seizure prophylaxis with phenytoin. In atraumatic bleeds, treatment should focus on lowering  blood pressure to reduce bleeding. References: https://www.a...

Author: Aaron Lessen, M.D. Educational Pearls Patients with an ischemic stroke from occlusion of the left middle cerebral artery often present with aphasia in addition to other neurological deficits. A recent study looked at patients presenting with suspected stroke. Of the 700 patients recruited, 3% had isolated aphasia on exam.  On follow-up, none of the 3% had evidence of stroke on imaging. Und...

Author: Aaron Lessen, M.D. Educational Pearls Post-intubation care should always include pain control and adequate sedation. Commonly used sedation agents include propofol, ketamine and versed. However, too much sedation is harmful. Deep sedation (RASS -4 to -5)  is associated with worse long-term outcomes. RASS of 0 to -2 is ideal, as long as the patient is comfortable. References: https://coreem...

Educational Pearls Subdural hematomas can happen in the elderly because of brain atrophy, and can manifest with neurological deficit. Subdural hematomas are caused by rupture of the bridging veins of the brain. This can be caused by trauma, brain atrophy, or possibly by anticoagulant use. They are crescent-shaped on head CT.   Epidural hematomas, in contrast, are caused by rupture of meningeal art...

Author: Don Stader, M.D. Educational Pearls Mucor/Rhizopus fungal infections usually present in diabetic or immunocompromised patients as a black, necrotic lesion on the face. The fungus invades the vasculature of the face, causing tissue ischemia and necrosis. The infection is more common in the diabetic population because the fungus prefers more acidic and glucose-rich environments. This is a su...

Author: John Winkler, M.D. Educational Pearls Angioedema is immediately life-threatening due to airway obstruction. Mechanisms include allergic reaction (histamine-related) or bradykinin-related (ACE-inhibitor, C1 esterase inhibitor deficiency). The bradykinin-related mechanism will not respond to the traditional meds used for anaphylaxis. Instead, use FFP to replace depleted factors. If a patient...

Author: Nick Hatch, M.D. Educational Pearls Unlike coin ingestions, button batteries can cause necrosis of the GI tract. If lodged in the esophagus, removal within 2 hours is important, because they can cause problems such as strictures or esophago-aortic fistula. If the battery is in the stomach or beyond, it may be ok to let it pass but give strict return precautions. Small hearing aid batteries...

Author: Aaron Lessen, M.D. Educational Pearls A recent prospective observational study was performed to examine the safety of different sedation medications in the pediatric ED. This study included 6000 children, and looked at the rate of serious adverse events following administration of different sedatives. Overall, the safest drug to use was ketamine alone, with an adverse event rate of about 1...

Author: Sam Killian, M.D. Educational Pearls Difficulty with bag valve mask (BVM) ventilation can be addressed using the MOANS mnemonic. M ask seal, O besity/obstruction,   A ge, N o teeth, S leep apnea. Often BVM difficulty can be addressed by an extra set of hands. References: https://www.aliem.com/2012/10/mnemonics-for-difficult-airway/