Emergency Medical Minute

Author:  Jared Scott, M.D. Educational Pearls Overall, medical providers are bad at detecting pulses. However, only 2% of patients do not have a detectable DP pulse. In one study, for patients with limb claudication, there was only about 50% agreement on the presence of a DP pulse. References: Brearley et al. Peripheral pulse palpation: an unreliable physical sign. Annals of the Royal College of S...

Author: Aaron Lessen, M.D. Educational Pearls Traditionally the family is removed from the room during procedures and codes, but recent research shows that family presence may be beneficial. 50% patients want family present during a code. Family-related outcomes were improved with presence. There was no change in medical outcomes, and no increased incidence of medicolegal issues. References: Jabre...

Author: Michael Hunt, M.D. Educational Pearls In the recent YEARS study, investigators checked every patient with suspicion for PE with a D-dimer, using a modified Wells score for risk stratification. The goal of the study was to show that CT scan usage could safely reduced using this screening method. The Wells Criteria measures they used to stratify risk were: PE mostly likely dx, hemoptysis, an...

Author: Jared Scott, M.D. Educational Pearls The foramen ovale (FO) connects the left and right atria to allow oxygenated blood to bypass the developing lungs, it usually closes at birth but for some it remains patent (PFO). A PFO allows clots to cross from the venous to arterial circulation, increasing the likelihood of stroke. PFO is present in 25% of general population, present in 50% of those...

Author: Don Stader, M.D. Educational Pearls Ear pain is a common complaint in adults and kids. A red, hot, painful ear with involvement of the pinna could indicate perichondritis - an infection of the cartilage that is usually caused by pseudomonas. A painful, swollen ear with involvement of the mastoid process could be mastoiditis, which needs to be treated with IV antibiotics to avoid cerebellar...

Author: Nick Hatch, M.D. Educational Pearls A recent observational cohort study found that the biggest predictor for sepsis survival was fever. Those with higher fevers had better outcomes. Some possible explanations for this finding are that high fevers indicate good immune response or that high fever cued providers to treat sepsis more aggressively. References: Paul J Young,  Rinaldo Bellomo. Fe...

Author: Dylan Luyten, M.D. Educational Pearls Hypoglycemia is very common in type 2 diabetics, and is often caused by insulin overdose or missed meals. Knowing the peak time of action for common diabetes medications can help inform treatment and disposition. Regular insulin's action peaks around 60 minutes. By the time most of these patients present to the ED, the drug has had most of its effect....

Author: Nick Hatch, M.D. Educational Pearls The force required to break a clavicle is significant, so clavicle fracture may be associated with other injury (pneumothorax, vascular injury). Most fractures occur in the middle 1/3 of the clavicle. Traditionally, clavicle fractures have been managed without surgery. However, recent studies have shown that surgery may be beneficial in a larger populati...

Author: Don Stader, M.D. Educational Pearls Cluster headaches are usually intense, unilateral,  and involve the periorbital area. CN V (Trigeminal) provides sensory and autonomic innervation the face and eyes, which play roles in headache pathology. Cluster headaches can be treated with high flow oxygen, but a new treatment involves blocking the sphenopalatine ganglion (SPG) with lidocaine. Becaus...

Author: Suzanne Chilton, M.D. Educational Pearls Pott's puffy tumor is a subperiosteal abscess of the frontal bone that arises from hematologic spread or direct infection via the frontal sinuses. The primary symptom is facial swelling. It is much more common in children and adolescents. Treatment involves removal of the frontal bone, reconstructive surgery, and 6-8 weeks of IV antibiotics. Referen...

Author: Dave Rosenberg, M.D. Educational Pearls MI and GERD can present similarly. For example, 47% with angina report increased belching with an anginal attack, and 20% of people with an MI describe symptoms  of indigestion that are relieved by antacids. Overall, GERD is more common in those with CAD, so don't be "reassured" by GERD symptoms in the setting of chest pain. References: http://www.md...

  Podcast #240: Honey and Burns Author: Nick Hatch, M.D. Educational Pearls Honey can be used to treat burns because it has antibacterial properties. In one study, honey outperformed silver sulfadiazine for burn treatment, but more research is needed in this area. In practice, honey is likely more useful outside the ER than inside the ER. References: Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S...

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist - Emergency Medicine Educational Pearls Tetanus Ig is indicated in those who have no or unknown tetanus vaccination history who present with contaminated cuts that or dirty puncture wounds The tetanus vaccine is a 5 shot series (DTAP) for children, TDAP is used for adults There is no harm is receiving the TDAP more than once if vaccination...

Author: Aaron Lessen M.D. Educational Pearls Ultrasound  is helpful in the setting of cardiac arrest for finding a cause like cardiac tamponade or PE, but also for predicting outcomes for non-shockable rhythms. One study showed that in those that presented with asystole or PEA and cardiac activity on US had a 4% survival rate, while those without cardiac activity had almost no chance. References:...

Author: Susan Brion, M.D.   Dr. Brion enlightens us on the ever-evolving standard of sepsis management.

Author: Sam Killian, M.D. Educational Pearls Phimosis refers to the inability to retract the distal foreskin over the glans penis in uncircumcised males. Paraphimosis is the entrapment of the foreskin proximal to the glans penis in these patients. Phimosis is rarely a medical emergency, but requires follow up with urology. Paraphimosis, on the other hand, can cause venous and lymphatic insufficien...

Author: Nick Hatch, M.D. Educational Pearls When peripheral or central IV access is difficult, sometimes providers will try to use a peripheral IV setup at an IJ site using US guidance. Case studies have shown that this method is often successful, with the most common complication being the loss of access. References: Ash AJ, Raio C. Seldinger Technique for Placement of "Peripheral" Internal Jugul...

Author: Pete Bakes, M.D. Educational Pearls One of the roles of the ER provider is to discharge patients only after life-threatening conditions have been ruled out. However, some patients that are discharged from the ED die within days of their discharge. One recent study sought to investigate the factors and diagnoses associated with death within 7 days of discharge. This study was a retrospectiv...

Author: Dylan Luyten, M.D. Educational Pearls Around 30% of patients in the ER receive CT imaging, and the sensitivity of CT imaging may be improved with IV contrast. However, contrast is often withheld for fear of contrast-induced nephropathy. A recent, single-center, retrospective cohort study compared the rates of nephropathy between contrast CT, non-contrast CT, and no CT control patients, and...

Author: Don Stader, M.D. and  Rachael Duncan, PharmD BCPS BCCCP Educational Pearls Carfentanil is an opioid elephant tranquilizer that can be used recreationally.  It is 1000 times stronger than fentanyl, and looks like a white powder. Healthcare workers must be cautious when carfentanil overdose is suspected, as the drug can be absorbed through caregivers' skin if it is present on the patient's c...

Author: Gretchen Hinson, M.D. Educational Pearls High-Altitude Pulmonary Edema (HAPE) is caused when hypoxemia due to low ambient pO2 leads to breakdown and constriction of the pulmonary vasculature leading to edema. HAPE is very rare under 8000 ft, but common over 10000 ft (6%). Over 18,000 ft the incidence is very high (12-15%). Symptoms include dyspnea, cough, weakness and chest tightness. Sign...

Author: Jared Scott, M.D. Educational Pearls Boerhaave syndrome (aka effort rupture of the esophagus) accounts for 10% of esophageal ruptures and is usually caused by strain during vomiting episodes. It can also be caused by childbirth, seizure, or prolonged coughing or laughing.   Food and water swallowed after the tear end up in the mediastinum, eventually causing infection. Therefore, Boerhaave...

Author: Aaron Lessen, M.D. Educational Pearls 2 studies this past year looked at pediatric and adolescent patients following a concussion. They found people who returned to activity sooner did better than those who went on "brain rest".   While patients should still follow up with their PCP following a concussion, it is ok for patients to return to physical activity as tolerated. References: Grool...

Author: Sam Killian, M.D. Educational Pearls Andrew Jackson was the 7th president of the USA. He served 2 terms from 1829-1837. He had had many medical issues during his presidency. He was said to be chronically underweight with rotting teeth. Furthermore, he had chronic infections and lead poisoning from bullets lodged in his arm and chest. He suffered from smallpox that he contracted while in a...

Author: Jared Scott, M.D. Educational Pearls BB gun eye injuries are most common in August and September. They most often happen to males aged 16-17 year old. Around 10% of the BB eye injuries lead to eye loss. Accidental firearm injury is common in children and is a common cause of mortality. One-third of homes with children have a firearm. Most accidental pediatric gun injuries happen to young,...