Emergency Medical Minute

Contributor: Aaron Lessen,MD Educational Pearls: R ecent study looked at mechanically ventilated patients in ED and ICU to determine if O2 saturation level impacted patient outcomes 2541 patients randomized to one of three target O2 saturation levels Low: 90% (Range: 88-92%) Intermediate: 94% (Range: 92-96%) High: 98% (Range: 96-100%) Outcome indicators Primary: Number of days alive and ventilator...

Contributor: Travis Barlock, MD Educational Pearls: Gauge and length of catheter are determinants of flow rate  Smaller gauges produce higher flow rate Longer catheters reduce flow rate   Common IV gauges produce predictable rates of flow:  20 gauge = 60 cc/min 18 gauge = 105 cc/min 16 gauge = 220 cc/min  Central lines typically have two 18 gauge and one 16 gauge lumen, both with long catheters, p...

Contributor: Aaron Lessen, MD Educational Pearls: Monkeypox transmission is still occurring  in the United States Transmitted by contact to exposed lesion MSM are a high-risk group for monkeypox infection Symptoms include rash and flu like symptoms Monkeypox lesions are often described as blister-like, firm, clear, and rubbery Most commonly develop on the face and/or anogenital regions Patients wi...

Contributor: Nick Hatch, MD Educational Pearls: In the setting of traumatic injury, tranexamic acid (TXA) is given to stabilize clots which minimizes bleeding and decreases risk of hemorrhagic shock   Current TXA dose for trauma is 1 g bolus followed by a 1 g infusion; both doses should be given within 3 hours from time of injury  Due to the split dose and narrow window, patients with complicated...

Contributor: Aaron Lessen, MD Educational Pearls: Recent study evaluated if early exposure to an allergen impacted the rate of allergy development later in childhood Children were exposed to peanut, milk, wheat, and egg allergens at 3 months of age and then followed for 3 years 2.5-3% of children who were not exposed developed allergies to these allergens 1% of children exposed to the allergens de...

Contributor: Travis Barlock, MD Educational Pearls: The presence of a STEMI has traditionally been used to determine if a patient with acute chest pain requires urgent cath lab management STEMI indicates an occluded coronary artery, and urgent intervention is needed to restore perfusion to ischemic tissue Patients with occluded coronary arteries can present with EKG findings other than STEMI 2022...

Contributor: Aaron Lessen, MD Educational Pearls: In urban settings, it is becoming more common for police to transport critical patients from scene to hospital A 2022 multicenter observational study compared mortality rates in patients with penetrating injury to torso and/or proximal extremity when transported by EMS versus police Approximately 18% of patients were transported by police  Overall...

Contributor: Travis Barlock, MD Educational Pearls: Catheter related blood infections were thought to be caused by skin flora seeding the catheter. Thus, significant effort is applied to sterility and skin preparation.   However, studies have shown that bacteria growing on the tip of the catheter is not consistent with growth on cultures of skin.   Staphylococcus epidermidis is commonly found on c...

Contributor: Jared Scott, MD Educational Pearls: Immediate resuscitative thoracotomy can be performed in the ED to gain rapid access to the thoracic cavity in cases of traumatic cardiac arrest Western Trauma Association Society Criteria for ED thoracotomy Blunt trauma +

Contributor: Aaron Lessen, MD Educational Pearls: Lateral Cutaneous Femoral Nerve Entrapment Syndrome, also known as Meralgia Paresthetica, results from entrapment of the lateral cutaneous femoral nerve, often as it exits the pelvis under the inguinal ligament.  Meralgia Paresthetica is associated with obesity, pregnancy, compression from clothing or belts and diabetes. Symptoms include numbness,...

Contributor: Travis Barlock, MD Educational Pearls: An EKG should be obtained quickly after a syncopal event to identify possible life-threatening causes such as ischemia and arrhythmia WOBBLER is a good mnemonic for remembering additional EKG findings to look for in syncope   W olff-Parkinson-White (WPW) Check for delta wave on QRS O bstructed AV node Any potential heart blocks B rugada syndrome...

Contributor: Don Stader, MD Educational Pearls: Home naloxone is traditionally given to those at high risk for opioid overdose such as those in the ED due to an opioid overdose, opioid intoxication, or admit to illicit opioid use         There are a number of other patient populations that benefit from home naloxone including those on chronic opioid or benzodiazepine therapy, and those who report...

Contributor: Jared Scott, MD Educational Pearls: Elevated lactate levels can be a useful indicator of critical illness in patients who meet SIRS criteri a         Lactate can also be elevated due to other causes including seizures and medications such as albuterol and metformin    A recent study from Switzerland* performed routine point-of-care lactate testing in all elderly patients presenting at...

Contributor: Don Stader, MD Educational Pearls: There are two major groups of local anesthetics: Amide and Esther  To recall what group an anesthetic belongs to, use this memory trick:   Amide has an 'i' in the name and Amide anesthetics have 2 'i's e.g., Lidocaine. Ester has no 'i' and most common Ester anesthetics have only one 'i' e.g., Tetracaine.   In a true allergy and/or contraindication to...

Contributor: Aaron Lessen, MD Educational Pearls: 2020 retrospective study with dat from two California hospitals compared rates of cardiovascular admissions in a five day period two weeks before and the five days after the presidential election      Hospitalization rate for acute cardiovascular disease increased by 17% and rate of acute myocardial infarction increased by 42%    Highest rates occu...

Contributor: Aaron Lessen, MD Educational Pearls: The management of severe asthma or COPD exacerbation is complex, especially when the patient requires intubation/ventilation Asthma is an obstructive airway disease that can cause air trapping and hyperinflation of the lungs To avoid worsening hyperinflation patients typically require slower respiratory rates, lower tidal volumes, and increased exp...

Contributor: Aaron Lessen, MD Educational Pearls: Historically, pancreatitis has been treated with aggressive IV fluid rehydration. Recently published data shows this may not be appropriate. A randomized, controlled, multi-hospital trial evaluated outcomes for patients with acute pancreatitis receiving lactated Ringer's solution    Aggressive fluid resuscitation group received 20ml/kg bolus + 3ml/...

Contributor: Aaron Lessen, MD Educational Pearls: Recent study looked at the impact of screen time on duration of post-concussive symptoms 125 patients aged 12-25 diagnosed with a concussion were randomized to either abstain from or have unrestricted screen time for 48 hours after injury Patients with unrestricted screen time averaged approximately 5 hours/day of screen time Patients in the no scr...

Contributor: Travis Barlock, MD Educational Pearls: Most oxygen in the body is bound to hemoglobin, forming oxyhemoglobin. Less than 1% of the oxygen in the body is dissolved in plasma.  Pulse Oximeters (Pulse Ox) function by emitting wavelengths of light from one side, and capturing the amount absorbed on the opposite side. A calculation determined the amount of saturation.  Pulse Ox relies on pu...

Contributor: Nick Tsipis, MD Educational Pearls: PO medications are less frequently used in the ED due to their longer onset of action         The position the patient is in when given PO medications may affect how quickly the medication is absorbed The quicker the medication passes through the stomach into the small intestine, the quicker it can be absorbed and metabolized Recent study used in si...

Contributor: Lessen, Aaron MD Educational Pearls: Ketamine can be given at 0.2-0.3 mg/kg as subdissociative doses for pain control in the ED Ketamine coadministered with Haldol may reduce agitation A recent study in Iran compared subdissociative Ketamine given with 2.5 mg Haldol to 1 mg/kg Fentanyl for pain control in the ED Ketamine with Haldol had better pain control than Fentanyl at 5, 10, 15 a...

Contributor: Jarod Scott, MD Educational Pearls: There is a 1-hour window for tooth replantation in ED Cold milk is often best transport media unless there is access to specialized solutions (Hank's Balanced Solution) Goal is to preserve periodontal ligament Soaking in tap water should be avoided as it will lyse cells of periodontal ligament      If oral surgeon is rapidly available, have them per...

Contributor: Aaron Lessen, MD Educational Pearls: Achilles tendon rupture usually presents in younger, healthy patients after a sports injury Patients typically present complaining of an abrupt onset ankle pain after feeling a "pop" Pain can be localized to posterior ankle and patient's lack the ability to plantarflex Achilles rupture is a clinical diagnosis and does not usually require imaging in...

Contributor: Dylan Luyten, MD Educational Pearls: Positive End Expiratory Pressure (PEEP) is positive pressure within the lungs and maintained throughout the entire respiratory cycle. It is the pressure preventing alveoli from collapsing at the en d of exhalation.  When using a bag valve mask (BVM) to ventilate patients, always attach the PEEP valve to prevent intrathoracic pressure from returning...

Contributor: Jared Scott, MD Educational Pearls: If a patient is in significant pain, a digital block can be helpful. Pain management alone may allow for manual ring removal.  Ring cutters and trauma shears with specialized ring cutters can be attempted but will destroy the ring and some materials may be resistant to cutting.  2 alternative options are presented which aim to reduce edema above the...