Emergency Medical Minute

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**Emergency Medical Minute**

Our near daily podcasts move quickly to reflect current events, are inspired by real patient care, and speak to the true nature of what it’s like to work in the Emergency Room or Pre-Hospital Setting. Each medical minute is recorded in a real emergency department, by the emergency physician or clinical pharmacist on duty – the ER is our studio and everything is live.

Latest Episodes:

Episode 923: Blunt Cerebrovascular Injury Sep 30, 2024

Show notes

Contributor: Travis Barlock MD

Educational Pearls:

Assessment of head and neck vascular injury due to blunt trauma

Symptomatic patients require screening head and neck CT angiography

EAST guidelines include the following criteria for a screening CT angiography in blunt head trauma:

Unexplained neurological deficits
Arterial nosebleed
GCS
Petrous bone fracture
Cervical spine fracture
Any size fracture through the transverse foramen
LeFort fractures type II or type III

EAST guidelines include a grading scale for vascular injury:

Grade I: Luminal irregularity or dissection with
Grade II: Dissection or intramural hematoma with >25% luminal narrowing, intraluminal thrombus, or raised intimal flap
Grade III: Pseudoaneurysm
Grade IV: Occlusion
Grade V: Transection with free extravasation

References

Bensch FV, Varjonen EA, Pyhältö TT, Koskinen SK. Augmenting Denver criteria yields increased BCVI detection, with screening showing markedly increased risk for subsequent ischemic stroke. Emerg Radiol. 2019;26(4):365-372. doi:10.1007/s10140-019-01677-0
Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178(6):517-522. doi:10.1016/s0002-9610(99)00245-7
Kim DY, Biffl W, Bokhari F, et al. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020;88(6):875-887. doi:10.1097/TA.0000000000002668

Summarized & Edited by Jorge Chalit, OMS3

Donate: https://emergencymedicalminute.org/donate/

Episode 922: Chest Tube Irrigation Sep 23, 2024

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Hemothorax: blood in the pleural cavity, most commonly due to chest trauma
Treatment: thoracostomy tube for blood drainage

helps to avoid clotting, scarring, and infection

A recent study looked at patients with hemothorax who either received or did not receive thoracic irrigation with saline

Evaluated incidence of secondary intervention, such as video-assisted thoracoscopic surgery (VATS), for persistent hemothorax
Patients who received irrigation had a slight decrease in secondary intervention frequency
Multi-center study - all patients who had the irrigation procedure were at two centers

Study limitation: variability in approaches at each location could be a confounder

Technique that could potentially prevent future complications

References

Carver TW, Berndtson AE, McNickle AG, et al. Thoracic irrigation for prevention of secondary intervention after thoracostomy tube drainage for hemothorax: A Western Trauma Association multi-center study. J Trauma Acute Care Surg. Published online May 20, 2024. doi:10.1097/TA.0000000000004364
Yi JH, Liu HB, Zhang M, et al. Management of traumatic hemothorax by closed thoracic drainage using a central venous catheter. J Zhejiang Univ Sci B. 2012;13(1):43-48. doi:10.1631/jzus.B1100161

Summarized by Meg Joyce, MS | Edited by Meg Joyce & Jorge Chalit, OMS3

Donate: https://emergencymedicalminute.org/donate/

Episode 921: Pediatric Hypoglycemia Sep 22, 2024

Show notes

Contributor: Taylor Lynch, MD

Educational Pearls:

When it comes to hypoglycemia, the age dictates possible causes

Neonate:

Hormonal deficiency

Congenital Adrenal Hyperplasia (21-hydroxylase deficiency, 11β-hydroxylase deficiency)
Primary or Secondary Adrenal Insufficiency leading to cortisol deficiency
Hypopituitarism

Inborn errors of metabolism
Systemic infection (Under 30 days old should trigger a full infectious workup)

Toddler

Accidental ingestions

Sulfonylureas such as glipizide or glyburide

Older children

Addison's Disease (Hypocortisolism)
Accidential or intentional ingestions
Exogenous insulin

How is it diagnosed?

Child or infant

Glucose

Newborn

Glucose

Treatment

Awake: oral glucose
Altered: IV glucose
Rule of 50's. The dose you give times the concentration should equal 50

Neonate to 2 months get 5 mg/kg of D10W (5*10=50)
2 months to 8 years old get 2 mg/kg of D25W (2*25=50)
Over 8 gets 1 mg/kg of D50W (1*50=50)
Bonus fact: Rough estimate of weight for a child is 2*patients age plus 8

Recheck sugar every 15 minutes
If they stay hypoglycemic give another bolus and consider starting a drip at 1.5 maintenance dose of D10NS.
If you don't have an IV you can consider glucagon at 0.03 mg/kg IM, although you might be better off trying glucose gel buccally.
If standard therapy still fails you can give hydrocortisone

25 mg IV for neonates and infants
50 mg IV for toddlers and smaller school aged children
100 mg for anyone older than that

How do you test for exogenous insulin?

Check a c-peptide which would be low if a patient is taking exogenous insulin

References

Lang, T. F., & Hussain, K. (2014). Pediatric hypoglycemia. Advances in clinical chemistry, 63, 211–245. https://doi.org/10.1016/b978-0-12-800094-6.00006-6
Lee, S. C., Baranowski, E. S., Sakremath, R., Saraff, V., & Mohamed, Z. (2023). Hypoglycaemia in adrenal insufficiency. Frontiers in endocrinology, 14, 1198519. https://doi.org/10.3389/fendo.2023.1198519
Thompson-Branch, A., & Havranek, T. (2017). Neonatal Hypoglycemia. Pediatrics in review, 38(4), 147–157. https://doi.org/10.1542/pir.2016-0063

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3

Donate: https://emergencymedicalminute.org/donate/

Laboring Under Pressure Episode 3: Hypertensive Disorders of Pregnancy with Dr. Kiersten Williams Sep 12, 2024

Show notes

Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS3

Show Pearls

Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide.
Hypertension (HTN) complicates 2-8% of pregnancies
The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart
There is a range of HTN disorders

Chronic HTN which could have superimposed preeclampsia (preE) on top
Gestational HTN in which there are no lab abnormalities
PreE w/o severe features

Protein in urine
Urine protein >300 mg in 24 hours
Urine Protein to Creatinine ratio of .3
+2 Protein on urine dipstick

PreE w/ severe features

Systolics above 160 mmHg
Diastolics above 110 mmHg
Headache, especially not going away with meds, or different than previous headaches
Visual changes, anything that lasts more than a few minutes
RUQ pain, which could present as heartburn
Pulmonary edema
Low platelets, if
Renal insufficiency, creatinine 1.1 or higher or doubling of baseline
Impaired liver function
Note: Hemoconcentration and LDH >600 are not diagnostic but worth paying attention to

Treatment

Labetalol, IV

Avoid in bradycardia, asthma, or myocardial disease
Quick up titrate, with dosing regimens such as 20-20-40 or 20-40-80 (mg)

Hydralazine, IV

5 mg starting, then another 5 mg then 10 mg if not working

Nifedipine, Oral

Can cause a headache

Goal is not to normalize BP but bring it down slowly

How to give magnesium

Start with 6 g or 4 g over 20 minutes if the patient is small or has bad kidney function
Follow with 2 g per hour or 1 g per hour
Don't give in myasthenia gravis

What should you do if the patient progresses to eclampsia (seizures)

Magnesium is the best drug
Can use phenytoin or benzos IV as an alternate
Diazepam is available PR which is a good option if you don't have IV access
IM magnesium is doable but painful, mix with lidocaine and split dose between the butt cheeks

Facts about post-partum PreE

20% of women will have HTN post-partum
Most resolve by 6 weeks
If it lingers past 6 months this is chronic HTN
If the patient has severe features (see above) they desevere 24 hours on magnesium while being monitored on the L&D floor
Post-partum is the most common time for strokes
Providers can be much more aggressive with HTN treatment because the fetus is no longer being exposed
Enalapril is safe in breast feeding
Some patients might need to give up breast feeding to be on even more aggressive HTN therapy
Are NSAIDs safe while breastfeeding?

Motrin is pretty safe

Pulm edema is a risk, be careful with fluids

Last pearl: Put pregnant patients in left or right lateral decubitus while in ER or put a folded towel under their hip to help with venous return which can also help with nausea

References

Metoki, H., Iwama, N., Hamada, H., Satoh, M., Murakami, T., Ishikuro, M., & Obara, T. (2022). Hypertensive disorders of pregnancy: definition, management, and out-of-office blood pressure measurement. Hypertension research : official journal of the Japanese Society of Hypertension, 45(8), 1298–1309. https://doi.org/10.1038/s41440-022-00965-6
Rana, S., Lemoine, E., Granger, J. P., & Karumanchi, S. A. (2019). Preeclampsia: Pathophysiology, Challenges, and Perspectives. Circulation research, 124(7), 1094–1112. https://doi.org/10.1161/CIRCRESAHA.118.313276
Reed, B. (2020, May 2). 'They didn't listen to me': Amber Rose Isaac tweeted about her death before dying in childbirth. The Guardian. https://www.theguardian.com/us-news/2020/may/02/amber-rose-isaac-new-york-childbirth-death
Reisner, S. H., Eisenberg, N. H., Stahl, B., & Hauser, G. J. (1983). Maternal medications and breast-feeding. Developmental pharmacology and therapeutics, 6(5), 285–304. https://doi.org/10.1159/000457330
Wilkerson, R. G., & Ogunbodede, A. C. (2019). Hypertensive Disorders of Pregnancy. Emergency medicine clinics of North America, 37(2), 301–316. https://doi.org/10.1016/j.emc.2019.01.008
Wu, P., Green, M., & Myers, J. E. (2023). Hypertensive disorders of pregnancy. BMJ (Clinical research ed.), 381, e071653. https://doi.org/10.1136/bmj-2022-071653

Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII

Episode 920: Pediatric Growth Estimates Sep 09, 2024

Show notes

Contributor: Sean Fox, MD

Educational Pearls:

Newborns may lose up to 10% of their birth weight in the first week of life

Weight loss is greatest in exclusively breastfed infants
Should regain birth weight by age 2 weeks

Newborns should gain an average of 30g (1 oz) per day in the first 3 months of life

Some will gain more and some will gain less

Infants double their birth weight by 6 months of life and triple their weight by 12 months

A 1-year-old should weigh on average 10 kg (22 lbs)
A 3-year-old should weigh on average 15 kg (33 lbs)
2-year-olds are between 10-15 kg on average

Weight assessment can help determine causes of forceful vomiting

Not all "projectile" vomiting is due to pyloric stenosis
Some infants may experience vigorous vomiting from overfeeding

Weight estimates can also provide information for quick decisions on medical management for children coming via EMS

Helps to prepare medications and dosages based on predicted average weight

References

Crossland DS, Richmond S, Hudson M, Smith K, Abu-Harb M. Weight change in the term baby in the first 2 weeks of life. Acta Paediatr. 2008;97(4):425-429. doi:10.1111/j.1651-2227.2008.00685.x
Grummer-Strawn LM, Reinold C, Krebs NF; Centers for Disease Control and Prevention (CDC). Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States [published correction appears in MMWR Recomm Rep. 2010 Sep 17;59(36):1184]. MMWR Recomm Rep. 2010;59(RR-9):1-15.
Macdonald PD, Ross SR, Grant L, Young D. Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonatal Ed. 2003;88(6):F472-F476. doi:10.1136/fn.88.6.f472
Paul IM, Schaefer EW, Miller JR, et al. Weight Change Nomograms for the First Month After Birth. Pediatrics. 2016;138(6):e20162625. doi:10.1542/peds.2016-2625

Summarized & Edited by Jorge Chalit, OMS3

Special thanks to the Carolinas Medical Center for their contribution to this episode

Donate: https://emergencymedicalminute.org/donate/

Episode 919: EKG Criteria for Adenosine Sep 04, 2024

Show notes

Contributor: Travis Barlock, MD

Educational Pearls:

SVT: supraventricular tachycardia

Pharmacotherapy for SVT includes drugs that block the AV node, such as adenosine

EKG criteria before adenosine administration in SVT

Regular rhythm
Monomorphic: all QRS complexes are identical

If the EKG is polymorphic, with QRS complexes displaying changing morphologies, it is unsafe to administer adenosine

Adenosine can worsen polymorphic VTach and lead to VFib

References

Ganz, Leonard I., and Peter L. Friedman. "Supraventricular Tachycardia." New England Journal of Medicine, vol. 332, no. 3, 19 Jan. 1995, pp. 162–173, https://doi.org/10.1056/nejm199501193320307.
Smith JR, Goldberger JJ, Kadish AH. Adenosine induced polymorphic ventricular tachycardia in adults without structural heart disease. Pacing Clin Electrophysiol. 1997;20(3 Pt 1):743-745. doi:10.1111/j.1540-8159.1997.tb03897.x
Viskin, Sami, et al. "Polymorphic Ventricular Tachycardia: Terminology, Mechanism, Diagnosis, and Emergency Therapy." Circulation, vol. 144, no. 10, 7 Sept. 2021, pp. 823–839, https://doi.org/10.1161/circulationaha.121.055783.

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

Donate: https://emergencymedicalminute.org/donate/

Episode 918: Automated Blood Pressure Cuffs Aug 26, 2024

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

How does an automated blood pressure cuff work?

Automated blood pressure cuffs work differently than taking a manual blood pressure.
While taking a manual blood pressure, one typically listens for Korotkoff sounds (turbulent flow) while slowly deflating the cuff.
An automatic blood pressure cuff only senses the pressure in the cuff itself and specifically pays attention to oscillations in the pressure caused by when the pressure of the cuff is between the systolic (heart squeezing) and diastolic (heart relaxed) pressures.
These oscillations are at a maximum when the pressure in the cuff matches the mean arterial pressure (MAP) and therefore the machines are most accurate at reporting the MAP.
The machines then use the MAP and other information about the oscillations to estimate the systolic and diastolic pressures, which are less accurate.

What should you do if you need more accurate systolic and diastolic blood pressures?

Take a manual blood pressure.
Get an arterial-line (a-line), which provides continuous data for the blood pressure at the end of a catheter.

What happens if the cuff is too big or too small for the patient?

If the cuff is too small it will overestimate the pressure.
If the cuff is too large it will underestimate the pressure.

What should you do if the cuff cycles a bunch of times before reporting a blood pressure?

It probably isn't very accurate so consider another method.

Bonus fact!

The MAP is not directly in the middle of the systolic and diastolic pressures but is weighted towards the diastolic pressure. The MAP can be calculated by adding two-thirds of the diastolic pressure to one third of the systolic pressure. For example if the BP is 120/90 the MAP is 100 mmHg.

References

Benmira, A., Perez-Martin, A., Schuster, I., Aichoun, I., Coudray, S., Bereksi-Reguig, F., & Dauzat, M. (2016). From Korotkoff and Marey to automatic non-invasive oscillometric blood pressure measurement: does easiness come with reliability?. Expert review of medical devices, 13(2), 179–189. https://doi.org/10.1586/17434440.2016.1128821
Liu, J., Li, Y., Li, J., Zheng, D., & Liu, C. (2022). Sources of automatic office blood pressure measurement error: a systematic review. Physiological measurement, 43(9), 10.1088/1361-6579/ac890e. https://doi.org/10.1088/1361-6579/ac890e
Vilaplana J. M. (2006). Blood pressure measurement. Journal of renal care, 32(4), 210–213. https://doi.org/10.1111/j.1755-6686.2006.tb00025.x

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3

Donate: https://emergencymedicalminute.org/donate/

Episode 917: Heat-Related Illnesses Aug 19, 2024

Show notes

Contributor: Megan Hurley, MD

Educational Pearls:

Heat cramps

Occur due to electrolyte disturbances
Most common electrolyte abnormalities are hyponatremia and hypokalemia

Heat edema

Caused by vasodilation with pooling of interstitial fluid in the extremities

Heat rash (miliaria)

Common in newborns and elderly
Due to accumulation of sweat beneath eccrine ducts

Heat syncope

Lightheadedness, hypotension, and/or syncope in patients with peripheral vasodilation due to heat exposure
Treatment is removal from the heat source and rehydration (IV fluids or Gatorade)

Heat exhaustion

Patients have elevated body temperature (greater than 38º C but less than 40º C)
Symptoms include nausea, tachycardia, headache, sweating, and others
Normal mental status or mild confusion that improves with cooling
Treatment is removal from the heat source and hydration

Classic heat stroke

From prolonged exposure to heat
Defined as a core body temperature > 40.5º C, though not required for diagnosis or treatment
Presentation is similar to heat exhaustion with the addition of neurological deficits including ataxia
Patients present "dry"

Exertional heat stroke

Prolonged exposure to heat during exercise
Similar to classic heat stroke but the patients present "wet" due to antecedent treatment in ice baths or other field treatments

Management of heat-related illnesses includes:

Cooling
Rehydration
Evaluation of electrolytes
Antipyretics are not helpful because heat-induced illnesses are not due to hypothalamic dysregulation

References

Casa DJ, McDermott BP, Lee EC, et al. Cold water immersion: the gold standard for exertional heatstroke treatment. Exerc Sport Sci Rev 2007; 35:141.
Ebi KL, Capon A, Berry P, et al. Hot weather and heat extremes: health risks. Lancet 2021; 398:698.
Epstein Y, Yanovich R. Heatstroke. N Engl J Med 2019; 380:2449.
Gardner JW, JA K. Clinical diagnosis, management, and surveillance of exertional heat illness. In: Textbook of Military Medicine, Zajitchuk R (Ed), Army Medical Center Borden Institute, Washington, DC 2001.
Khosla R, Guntupalli KK. Heat-related illnesses. Crit Care Clin 1999; 15:251.
Lipman GS, Gaudio FG, Eifling KP, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Heat Illness: 2019 Update. Wilderness Environ Med 2019; 30:S33.

Summarized by Jorge Chalit, OMSIII | Edited by Meg Joyce, MS1

Donate: https://emergencymedicalminute.org/donate/

Episode 916: Central Cord Syndrome Aug 12, 2024

Show notes

Contributor: Taylor Lynch, MD

Educational Pearls:

What is Central Cord Syndrome (CCS)?

Incomplete spinal cord injury caused by trauma that compresses the center of the cord
More common in hyperextension injuries like falling and hitting the chin
Usually happens only in individuals with preexisting neck and spinal cord conditions like cervical spondylosis (age-related wear and tear of the cervical spine)

Anatomy of spinal cord

Motor tracts

The signals the brain sends for the muscles to move travel in the corticospinal tracts of the spinal cord
The tracts that control the upper limbs are more central than the ones that control the lower limbs
The tracts that control the hands are more central than the ones that control the upper arm/shoulder

Fine touch, vibration, and proprioception (body position) tracts

These sensations travel in separate tracts in the spinal cord than the sensation of pain and temperature
Their pathway is called the dorsal column-medial lemniscus (DCML) pathway
This information travels in the most posterior aspect of the spinal cord

Pain, crude touch, pressure, and temperature tracts

These sensations travel in the spinothalamic tract, which is more centrally located
These signals also cross one side of the body to the other within the spinal cord near the level that they enter

How does this anatomy affect the presentation of CCS?

Patients typically experience more pronounced weakness or paralysis in their upper extremities as compared to their lower extremities with their hands being weaker than more proximal muscle groups
Sensation of pain, crude touch, pressure, and temperature are much morelikely to be diminished while the sensation of fine touch, vibration, and proprioception are spared

What happens with reflexes?

Deep tendon reflexes become exaggerated in CCS
This is because the disruption in the corticospinal tract removes inhibitory control over reflex arcs

What happens to bladder control?

The neural signals that coordinate bladder emptying are disrupted, therefore patients can present with urinary retention and/or urge incontinence

What is a Babinski's Sign?

When the sole of the foot is stimulated a normal response in adults is for the toes to flex downward (plantar flexion)

If there is an upper motor neuron injury like in CCS, the toes will flex upwards (dorsiflexion)

How is CCS diagnosed?

CCS is mostly a clinical diagnosis
These patient also need an MRI to see the extent of the damage which will show increased signal intensity within the central part of the spinal cord on T2-weighted images

How is CCS treated?

Strict c-spine precautions
Neurogenic shock precautions. Maintain a mean arterial pressure (MAP) of 85-90 to ensure profusion of the spinal cord
Levophed (norepinephrine bitartrate) and/or phenylephrine can be used to support their blood pressure to support spinal perfusion
Consider intubation for injuries above C5 (C3, 4, and 5 keep the diaphragm alive)
Consult neurosurgery for possible decompression surgery
Physical Therapy

References

Avila, M. J., & Hurlbert, R. J. (2021). Central Cord Syndrome Redefined. Neurosurgery clinics of North America, 32(3), 353–363. https://doi.org/10.1016/j.nec.2021.03.007
Brooks N. P. (2017). Central Cord Syndrome. Neurosurgery clinics of North America, 28(1), 41–47. https://doi.org/10.1016/j.nec.2016.08.002
Engel-Haber, E., Snider, B., & Kirshblum, S. (2023). Central cord syndrome definitions, variations and limitations. Spinal cord, 61(11), 579–586. https://doi.org/10.1038/s41393-023-00894-2

Summarized by Jeffrey Olson, MS3 | Edited by Jorge Chalit, OMS3

Donate: https://emergencymedicalminute.org/donate/

Episode 915: Severe Burn Injuries Aug 05, 2024

Show notes

Contributor: Megan Hurley, MD

Educational Pearls:

Initial assessment of patients with severe burn injuries begins with ABCs

Airway: consider inhalation injury
Breathing: circumferential burns of the trunk region can reduce respiratory muscle movement
Circulation: circumferential burns compromise circulation
Exposure: Important to assess the affected surface area

Escharotomy: emergency procedure to release the tourniquet-ing effects of the eschar

Differs from a fasciotomy in that it does not breach the deep fascial layer

PEEP = positive end-expiratory pressure

The positive pressure remaining in the airway after exhalation
Keeps airway pressure higher than atmospheric pressure

Common formulas for initial fluid rate in burn shock resuscitation

Parkland formula: 4 mL/kg body weight/% TBSA burns (lactated Ringer's solution)
Modified Brooke formula: 2 mL/kg/% (also lactated Ringer's solution)

Less fluid = lower risk of intra-abdominal compartment syndrome

Lactated Ringer's solution is preferred over normal saline in burn injuries

Normal saline is avoided in large quantities due to the possibility of it leading to hyperchloremic acidosis

References

Acosta P, Santisbon E, Varon J. "The Use of Positive End-Expiratory Pressure in Mechanical Ventilation." Critical Care Clinics. 2007;23(2):251-261. doi:10.1016/j.ccc.2006.12.012
Orgill DP, Piccolo N. Escharotomy and decompressive therapies in burns. J Burn Care Res. 2009;30(5):759-768. doi:10.1097/BCR.0b013e3181b47cd3
Snell JA, Loh NH, Mahambrey T, Shokrollahi K. Clinical review: the critical care management of the burn patient. Crit Care. 2013;17(5):241. Published 2013 Oct 7. doi:10.1186/cc12706

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit

Donate: https://emergencymedicalminute.org/donate/

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