Emergency Medical Minute

Author: David Rosenberg, M.D. Educational Pearls A study of 20,000 subjects found that reducing fever in sepsis did not improve outcomes such as morbidity, mortality, or length of stay. However, correcting fever may help for patient comfort. References: Zhang Z, Chen L, Ni H. Antipyretic Therapy in Critically Ill Patients with Sepsis: An Interaction with Body Temperature. Azevedo LCP, ed. PLoS ONE...

Author: Chris Holmes, M.D. Educational Pearls The nexus chest CT scan rule is based on an 11,000 subject, multicenter study that looked for signs following a trauma that predicted significant findings on subsequent chest CT. Findings that were associated with abnormal chest CT included: abnormal CXR, distracting injury, chest wall, sternal, thoracic spine or scapular tenderness. Furthermore, a mec...

Author: Don Stader, M.D. Educational Pearls Wound botulism should be considered in patients with cutaneous lesions and  neuromuscular weakness. The toxin produced by clostridium botulinum is the causative agent. It forms spores, so it is very resistant to killing by heat. It presents with weakness, most often in the extraocular muscles. Treatment includes wound care and respiratory support. Anti-t...

Author: Michael Hunt, M.D. Educational Pearls Tattoo ink is applied below the skin, and because of this, they can lead to keloids, granulomas, tetanus, hepatitis B and C,  and skin infections. Tattoo pigment has been found to contain substances like lead, cadmium, chromium, and arsenic; however, there are no long-term studies of the health effects of tattoos. In one study 14% of inks had ingredien...

Author:  Dave Rosenberg, M.D. Educational Pearls Poiseuille's Law addresses the flow of a fluid through a tube. Many common ED presentations involve alterations in flow: asthma, MI, ischemic stroke, etc. According to the law, flow increases with the 4th power of the radius. That is to say, doubling the radius of the tube will increase the flow by 16x. Therefore, in situations that require re-openi...

Author: Dylan Luyten, M.D. Educational Pearls Lactate is a byproduct of anaerobic metabolism, a sign of dying tissue. Dangerous causes of high lactates will not normalize with repeat labs. Crush injuries, seizures, bowel necrosis,  end-stage liver disease, and metformin toxicity are common causes of highly elevated lactate. References: https://lifeinthefastlane.com/ccc/lactic-acidosis/

Author: John Winkler, M.D. Educational Pearls Some risk factors for MI in the young are history of CAD, stimulant drug use, coronary spasm and diabetes. In those with diffuse ST elevations on EKG, think pericarditis. Troponin will also be elevated. References: Egred M, Viswanathan G, Davis GK Myocardial infarction in young adults Postgraduate Medical Journal 2005;81:741-745.

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist - Emergency Medicine Educational Pearls CDC recommends using the inactivated, injectable flu vaccine in those 6 months and older. The live attenuated vaccine is not used because of low efficacy. Pregnant women should be vaccinated, and can receive the vaccine at any stage of their pregnancy. The vaccine is contraindicated ONLY in those wit...

Author: Aaron Lessen, M.D. Educational Pearls For patients with in-hospital cardiac arrest, intubation in the 1st 15 minutes of resuscitation was associated with worse outcomes (mortality, neurologic outcome). This is likely due to cessation of high-quality CPR and defibrillation during the intubation sequence. In those with an in-hospital, shockable, cardiac arrest, administration of epinephrine...

Educational Pearls After the first hour, every 1 hour delay in antibiotics in a patient with septic shock patient is associated with a 4% increase in mortality. In patients with high suspicion for septic shock (fever and hypotension), antibiotics should be initiated ASAP. Rocephin (ceftriaxone) should be used for those with community-acquired sepsis, zosyn for nosocomial or IV-associated sepsis. R...

Author: Julian Orenstein, M.D. Educational Pearls Colorado has a high population of unvaccinated children, and is at increased risk for pertussis outbreaks. The causative organism is Bordetella pertussis . It causes  causes respiratory epithelial necrosis leading to congestion of the bronchioles, leading to cough. The cough is unique - it is usually a series of expiratory coughs followed by one de...

Authors: Katie Sprinkel, MD Emergency Medicine Physician SANE Medical Director, Medical Center of Aurora    Amy Ferrin, Senior Deputy District Attorney County Court Supervisor Office of the District Attorney, 18th Judicial District Amy Ferrin and Dr. Katie Sprinkel speak about the medical and legal aspects of domestic violence.  

Author: Aaron Lessen, M.D. Educational Pearls Icatibant was introduced to treat ACE-inhibitor induced angioendema. This type of angioedema is refractory to epinephrine and antihistamines, and is likely mediated by elevated bradykinin.(which is inactivated by ATII and ACE). Icatibant initially was shown to reduce facial swelling and airway obstruction in the setting of ACE-I angioedema, but later,...

Author: David Rosenberg, M.D. Educational Pearls Preoxygenation is done before rapid sequence intubation, and should be done even if SaO2 is at 100%. Preoxygenation is done to fill the lungs with oxygen rather than ambient air, which is only 20% O2. While the patient is paralyzed, the O2-filled lungs will continue to oxygenate venous blood, buying you more time for intubation.   BiPAP is an effect...

  Podcast #259: TIA Author: Peter Bakes, M.D. Educational Pearls A TIA is defined as focal neurological deficit that resolves within 24 hours and has negative imaging. The etiology is a transient thrombus, embolus, or narrowing of a branch of a cerebral artery. Screening tests are generally negative and low-yield. MRI and vascular imaging are usually done to look for reversible causes. Patients pr...

Author:  Dylan Luyten, M.D. Educational Pearls Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Exsanguination is a major cause of mortality in trauma One temporizing technique to buy time to definitive hemorrhage control is to occlude the aorta thereby shunting blood away from pelvis and lower extremities, increasing cardiac afterload to increase myocardial and brain perfusion....

Educational Pearls Strangulation is common in cases of domestic violence and sexual assault, and it is associated with higher mortality People who have been strangled have a higher rate of stroke due to vascular damage to carotid artery Only 50% of people who die from strangulation show external signs of trauma CTA should be done in all those who experience LOC or incontinence from strangulation  ...

Authors: Don Stader, M.D & Rachael Duncan, PharmD BCPS BCCCP Educational Pearls Fentanyl patches may be abused in many ways, including changing the patches more frequently, chewing them, extracting the fentanyl in a tea, and administering them rectally. Fentanyl is very lipophilic and has a fast onset, but it has a very low bioavailability when given enterally, because it does not survive the stom...

Author: Heidi Wald, MD, MSPH  Associate Professor of Medicine - University of Colorado School of Medicine, Physician Advisor - Colorado Hospital Association Dr. Heidi Wald explains common misconceptions of UTI's in elderly patients and provides tips on how to properly identify them.  References: Trestioreanu , Adi Lador , May-Tal Sauerbrun-Cutler and Leonard Leibovici   Antibiotics for asymptomati...

Author: Erik Verzemnieks, M.D. Educational Pearls Posterior vitreous detachment is the tearing of the lining in the back of of the eye. Patients often present with loss of vision and floaters. Diagnosis can be made with US. This is a benign diagnosis, but 10-15% can progress to retinal detachment , so follow up  with ophthalmology is recommended. References: http://www.medscape.com/viewarticle/513...

Author: Chris Holmes, M.D. Educational Pearls There's little/no data about the necessary length of an antibiotic course, nor has it proven that stopping a course of antibiotics early selects for the most resistant bugs. There's little incentive for drug companies to fund this type of study. Pro-calcitonin levels have been used in some settings to distinguish if an infection has resolved or not, bu...

Author: Nick Hatch, M.D. Educational Pearls Photic or solar retinitis occurs when you stare at the sun. The refractive power of the lens of the eye concentrates the light of the sun on the retina, stimulating the production of free radicals, damaging photoreceptors. Solar retinitis may present hours-days after light exposure. Patients will present with patchy loss of vision without pain, since the...

Author: Sam Killian, M.D. Educational Pearls The tongue blade test is done for mandible fractures, which make up 40-60% of facial fractures. The test is done by having the patient bite down on a tongue depressor on one side of the mouth. The provider then tries to snap the tongue depressor. This is repeated on the other side of the mouth. The test is positive if the patient complains of pain befor...

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist – Emergency Medicine Educational Pearls Cyanide poisoning is suspected in patients who present with lactic acidosis after being trapped around burning household objects. It affects our ability to metabolize and can quickly lead to CV collapse and death.   Because cyanide blood levels are not quickly available, the diagnosis is made by hist...

Author: Rachael Duncan, PharmD BCPS BCCCP Educational Pearls Desmopressin is an ADH mimetic and helps retain water, release von Willibrand Factor (in high doses), and treat diabetes insipidus (in low doses). It can also be used in renal colic, because it may reduce muscle spasm in the ureters. The dosing for renal colic is very small (40 micrograms). References: http://reference.medscape.com/drug/...