Emergency Medical Minute

Author: Donald Stader, M.D. Educational Pearls: The most common ankle injury mechanism is an inversion. Most common broken bone in the ankle is the fibula. During exam, it is important to palpate over the fibular head, medial and lateral malleoli, over the 5th metatarsal and over the cuboid bone. If no tenderness in these areas and the patient is walking - they have a  sprain and can be sent home...

Author: Aaron Lessen, M.D. Educational Pearls: We can differentiate verto into benign problems such as vestibular problem (peripheral problem), or something more worrisome that originates in the brain (central problem). Dizziness + other symptoms makes us think about origination in the CNS.  Symptoms include Dizziness, Diplopia, Dysarthria, Dysphagia, Dysmetria. References:   http://www.medicalnew...

Author: Michael Hunt, M.D. Educational Pearls: Oats have been shown to lower LDL. Oat bran is the most effective way to consume oats to lower LDL. A Swedish study of 69,000 people who ate at least 3 servings of potatoes a week showed no increased risk of a MI or stroke associated with potato consumption. References: Larsson SC , Wolk A. Potato consumption and risk of cardiovascular disease: 2 pros...

Author: Jared Scott, M.D. Educational Pearls: A pessary is a device inserted into the vagina for medical purposes. Examples include birth control and mechanical support of the pelvic structures. In older women, collapse of the pelvic structures is common, and many may have pessaries to aid in treatment. References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876320/

Author: Michael Hunt, M.D. Educational Pearls: Children under age of 6 are at greatest risk of accidental nicotine overdose from ingestion. Biphasic presentation: Hyperadrenergic = nausea, vomiting, tachycardia, flushing. Bradycardia and respiratory depression. References: http://www.aapcc.org/alerts/e-cigarettes/ Mayer B. How much nicotine kills a human? Tracing back the generally accepted lethal...

Author: Jared Scott M.D. Educational Pearls: Bear mauling is not a common issue in the ED. The Ursus americanus (black bear) is the most common in Colorado, but Ursus arctos horribilis ( grizzly bear) attacks are more frequent because they are more aggressive. Head and neck lacerations are the most common injuries. Complications include infection and long term PTSD. Most bear attacks are defensive...

Author: Sam Killian, M.D. Educational Pearls: "The Rabbit Has Died" is a lesser used phrase to denote finding out one is pregnant. During a test used in the 1930s, the "Rabbit's Test," a rabbit was injected with a potentially pregnant woman's urine.  If the woman was pregnant, the rabbit would begin displaying signs of pregnancy itself. This test required killing the rabbits to visualize the ovari...

Author: Martin O'Bryan M.D. Educational Pearls: Vocal cord dysfunction can mimic other causes of stridor, such as asthma and upper airway obstruction. Patients are often very anxious because of the difficulty of inspiration. The definitive diagnosis is laryngoscopy that must be done by a pulmonologist. The treatment is general reassurance, asthma medications will not help. CPAP and heliox can be u...

Author: Sam Killian, M.D. Educational Pearls: Defined as fracture of neck (distal segment) of 5th metacarpal. Intrinsic muscles of hand pull segment to palmar aspect of hand. 30 degrees of angulation is allowed. Any more increases risk of chronic pain, grip strength and grasping deficits, and rotational deformities. Reduce fracture if more than 30 degrees of angulation or if rotation is present. S...

Author: Jared Scott, M.D. Educational Pearls: DDx for blood at urethral meatus includes: pelvic fracture, ruptured bladder, kidney laceration, penile trauma. Retrograde Urethrogram (RUG) must be performed before placing foley and is critical for diagnosis. References:  https://www.ncbi.nlm.nih.gov/pubmed/16488282

Author: Michael Hunt, M.D. Educational Pearls: Research has shown that the higher temperatures post-cardiac arrests may lead to poorer outcomes. Initially, 33 deg C was the target temp. However, more research is being done to find therapeutic temperature levels. New studies have shown that the cooling protocol differs for inpatient cardiac arrests vs. outpatient cardiac arrests.   The results show...

Authors:   Rebecca van Vliet   MS, APN;  Michelle Whaley MSN, CNS, CCNS, ANVP-VC The Stroke Team at Swedish Medical Center gives us a taste of how they are breaking records with door-to-needle time in management of acute cerebrovascular accidents.  

Author: Aaron Lessen M.D. Educational Pearls:   Thoracotomy is a potentially life-saving procedure. However, outcomes are often poor and the procedure itself poses many risks to provider and patient. Chance of surviving a thoracotomy when there is no cardiac activity on ultrasound is 0%. Performing a thoracotomy is unlikely to benefit patients with no cardiac activity on ultrasound or patients tha...

Author: Dave Rosenberg M.D. Educational Pearls: Louis Pasteur developed the technique that is now known as pasteurization. It was first used in the wine-producing regions of France, and eventually in dairy products like milk. Pasteur also investigated infectious disease. During one experiment, Pasteur's lab assistant accidentally infected chickens with a weakened form of cholera. When none of the...

Author: Susan Brion M.D. Educational Pearls: Laundry and dishwasher detergent pods resemble candy and can be ingested by children. These tide pods are very highly concentrated and can cause chemical burns of the lips, airway, eyes, mouth and esophagus. The strong bases in detergent pods (pH>12) can cause liquefactive necrosis, which can cause immediate perforation of the esophagus. Common symptoms...

Author: Mark Kozlowski M.D. Educational Pearls: Humans cannot "multitask" effectively - a more accurate term is "task interruption." When doing more than one task at once, we are more likely to forget key details and perform both tasks more slowly overall. Do not interrupt people who are focusing on critical tasks - programming a pump or drawing up doses. Think about ways to reduce task interrupti...

Author: Don Stader M.D. Educational Pearls: Non-traumatic back pain is a very common complaint in the Emergency Department. Conditions that can manifest with back pain include: ruptured abdominal aortic aneurysm, retroperitoneal bleeding, cauda equina syndrome, epidural abscess or cancer. Patients with cauda equina syndrome or epidural abscess prefer to sit forward, while people with disc issues t...

Author: Arthur Lessen M.D. Educational Pearls: Zofran ( ondansetron) is generally safe to use for the treatment of nausea and vomiting. However, it can prolong the QT interval and increase the chance for torsades.   Low doses of Zofran are not likely to be an issue. However, when multiple doses are given, especially in the setting of a preexisting LQTS, clinical concern should be raised. When givi...

Author: Aaron Lessen M.D. Educational Pearls: Imodium (loperamide) is a mu-opioid receptor agonist. Traditionally, it is used as an anti-diarrheal. It is also abused recreationally for an opioid high and to self-treat opioid withdrawal. 40 or more pills are often ingested. People often co-ingest with cimetidine to potentiate the desired effects. Patients will present with opioid overdose symptoms...

Author: Dylan Luyten M.D. Educational Pearls: Ashman's Phenomenon occurs in the setting atrial fibrillation and mimics ventricular tachycardia, but is harmless. On ECG, the pattern of Ashman Phenomenon is a long cycle, followed a short cycle, followed by a complex wide complex beat. The wide complex beats have  right BBB morphology. The long R-R followed by a short R-R leads to conduction down the...

Author: Samuel Killian M.D. Educational Pearls: Lower extremity DVTs are extremely common. There are more left lower extremity DVT due to anatomical variation. May-Thurner Syndrome is a form of anatomical variation in which the left iliac artery compresses the left iliac vein. Anticoagulation may not be sufficient to treat those with May-Thurner syndrome - endovascular stenting may be needed Patie...

Author: Don Stader, M.D Educational Pearls: It is important for providers to know how to use IV drugs properly so that they can instruct their patients on how to avoid injury. Heroin use is increasing. Hepatitis, HIV and infection are possible complications of improper IV drug use The first step of heroin use is to dissolve the solid heroin in water using heat - a spoon and lighter are often used...

Author: Peter Bakes, M.D Educational Pearls Intracerebral hemorrhage is an intracranial bleed within the brain tissue or ventricles. Subarachnoid aneurysm causes about 50% of all ICH. Amyloid deposition can lead to ICH in elderly patients. Hypertension is another common cause of atraumatic ICH, commonly leading to pontine, cerebellar, or basal ganglial bleeding. Bleeding in other locations is sugg...

Author: JP Brewer M.D. Educational Pearls: The "Quick Wee" was a method to get urine out of infants who need to have a UA in the Emergency Department. A randomized-controlled experiment was done with 350 infants between the ages of 1 to 12 months. The "Quick Wee" method is taking a sterile saline gauze with cool saline and rubbing it over the suprapubic abdomen for five minutes. The results were s...

Author: Jared Scott M.D. Educational Pearls: There are two anatomical triangles on the back, the inferior lumbar triangle and the superior lumbar triangle. Herniation occurs whenever something moves to a place where it is not supposed to be, often through a fascial weakness. A "back hernia" can happen when the contents of of the abdominal cavity herniate into the back, usually through the superior...