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:

Podcast 876: Sedation Pearls Nov 06, 2023

Show notes

Contributor: Travis Barlock MD

Educational Pearls:

Common sedatives used in the Emergency Department and a few pearls for each.

Propofol

Type: Non-barbiturate sedative hypnotic agonizing GABA receptors.
Benefit: Quick on and quick off (duration of action is approximately 2-7 minutes), helpful for suspected neurologic injury so the patient can wake up and be re-evaluated. Also has the benefit of reducing intracranial pressure (ICP).
Downsides: Hypotension, bradycardia, respiratory depression.
What should you do if a patient is getting hypotensive on propofol?

Do not stop the propofol. Start pressors. May have to reduce the propofol dose if delay in pressors.

Dexmedetomidine (Precedex)

Type: Alpha 2 agonist - causes central sedation
Uses: Patients are more alert and responsive and therefore can be on BiPAP instead of being intubated. Does not cause respiratory depression.
Downsides: Hypotension and Bradycardia.
Caution in using this for head injuries, its side effects can mask the Cushing reflex and make it more difficult to spot acute elevations in ICP and uncal herniation.

Ketamine

Type: NMDA antagonist and dissociative anesthetic, among other mechanisms.
Benefits: Quick Onset (but slower than propofol). Does not cause hypotension, but can even increase HR and BP (Thought to potentially cause hypotension if patient is catecholamine-depleted (ie. sepsis, delayed trauma)).
Dosing ketamine can be challenging. Typically low doses (0.1-0.3mg/kg (max ~30mg)) can give good pain relief. Higher doses (for intubation/procedural sedation) are generally thought to have a higher risk of dissociation.
Downsides: Emergence reactions which include hallucinations, vivid dreams, and agitation. Increased secretions.

Benzos

Type: GABA agonists.
Benefits: Seizure, alcohol withdrawal, agitation due to toxic overdoses.
Push doses are useful because doses can stack. Longer half-life than propofol.
Downsides: Respiratory depression. Longer half-life can make neuro assessments difficult to complete.

Etomidate

MOA: Displaces endogenous GABA inhibitors.
Useful as a one-time dose for quick procedures (cardioversion, intubation). Often drug of choice for intubation since it is thought to have no hemodynamic effects.
Downsides; If used without paralytic - myoclonus. Though to have some adrenal suppression.

Fentanyl

Type: Opioid analgesic. Not traditional sedative.
Benefits: There are many instances in emergency medicine in which sedation can be avoided by prioritizing proper analgesia. Fentanyl can even be used to maintain intubated patients without needing to keep them constantly sedated.
Downsides: Respiratory depression. Patients may have tolerance.

References

Chawla N, Boateng A, Deshpande R. Procedural sedation in the ICU and emergency department. Curr Opin Anaesthesiol. 2017 Aug;30(4):507-512. doi: 10.1097/ACO.0000000000000487. PMID: 28562388.
Keating GM. Dexmedetomidine: A Review of Its Use for Sedation in the Intensive Care Setting. Drugs. 2015 Jul;75(10):1119-30. doi: 10.1007/s40265-015-0419-5. PMID: 26063213.
Lundström S, Twycross R, Mihalyo M, Wilcock A. Propofol. J Pain Symptom Manage. 2010 Sep;40(3):466-70. doi: 10.1016/j.jpainsymman.2010.07.001. PMID: 20816571.
Matchett G, Gasanova I, Riccio CA, Nasir D, Sunna MC, Bravenec BJ, Azizad O, Farrell B, Minhajuddin A, Stewart JW, Liang LW, Moon TS, Fox PE, Ebeling CG, Smith MN, Trousdale D, Ogunnaike BO; EvK Clinical Trial Collaborators. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med. 2022 Jan;48(1):78-91. doi: 10.1007/s00134-021-06577-x. Epub 2021 Dec 14. PMID: 34904190.
Mihaljević S, Pavlović M, Reiner K, Ćaćić M. Therapeutic Mechanisms of Ketamine. Psychiatr Danub. 2020 Autumn-Winter;32(3-4):325-333. doi: 10.24869/psyd.2020.325. PMID: 33370729.
Nakauchi C, Miyata M, Kamino S, Funato Y, Manabe M, Kojima A, Kawai Y, Uchida H, Fujino M, Boda H. Dexmedetomidine versus fentanyl for sedation in extremely preterm infants. Pediatr Int. 2023 Jan-Dec;65(1):e15581. doi: 10.1111/ped.15581. PMID: 37428855.

Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII

Podcast 875: A Pediatric Case of Myopericarditis Oct 30, 2023

Show notes

Contributor: Meghan Hurley MD

Educational Pearls:

Pericarditis is inflammation of the pericardial sac, which can arise from infectious or non-infectious etiologies
Myocarditis is inflammation of the myocardium, which may accompany pericarditis
Pericarditis clinical findings include:

Diffuse concave ST elevation, classic for acute pericarditis with myocardial involvement. More common in younger male patients
Elevated high-sensitivity troponin - higher levels may occur in young healthy patients
Ultrasound may show pericardial effusions

POCUS may be helpful in assessing left ventricular ejection fraction (LVEF) via E-point septal separation (EPSS)

Elevation in EPSS correlates with decreased LVEF

Treatments:

Anti-inflammatories including NSAIDs and colchicine
Monitor inflammation
Repeat ultrasounds

Risk factors in this patient's case:

mRNA COVID vaccine - the risk of myocarditis from vaccination is significantly lower than that from COVID-19 infection
Preceding infection

References

1. Gao J, Feng L, Li Y, et al. A Systematic Review and Meta-analysis of the Association Between SARS-CoV-2 Vaccination and Myocarditis or Pericarditis. Am J Prev Med. 2023;64(2):275-284.

2. Imazio M, Gaita F, LeWinter M. Evaluation and treatment of pericarditis: A systematic review. JAMA - J Am Med Assoc. 2015;314(14):1498-1506. doi:10.1001/jama.2015.12763

3. Mckaigney CJ, Krantz MJ, La Rocque CL, Hurst ND, Buchanan MS, Kendall JL. E-point septal separation: A bedside tool for emergency physician assessment of left ventricular ejection fraction. Am J Emerg Med. 2014;32(6):493-497. doi:10.1016/j.ajem.2014.01.045

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

Episode 874: Bradyarrhythmias Oct 23, 2023

Show notes

Contributor: Dylan Luyten MD

Educational Pearls:

What is a Bradyarrhythmia?

Also known as a bradyarrhythmia, it is an irregular heart rate that is also slow (below 60 beats per minute).

What can cause it?

Complete heart block AKA third-degree AV block; identified on ECG by a wide QRS, and complete dissociation between the atrial and ventricular rhythms with the ventricular being much slower. Treat with a pacemaker.
Medication overdose, especially beta blockers. Many other drugs can slow the heart as well including: opioids, clonidine, digitalis, amiodarone, diltiazem, and verapamil to name a few.
Electrolyte abnormalities, specifically hyperkalemia. Hypokalemia, hypocalcemia, and hypomagnesemia can also cause bradyarrhythmias.
Myocardial infarction. Either by damaging the AV node or the conduction system itself or by triggering a process called Reperfusion Bradycardia.
Hypothermia. Bradycardia is generally a sign of severe or advanced hypothermia.

References

Jurkovicová O, Cagán S. Reperfúzne arytmie [Reperfusion arrhythmias]. Bratisl Lek Listy. 1998 Mar-Apr;99(3-4):162-71. Slovak. PMID: 9919746.
Simmons T, Blazar E. Synergistic Bradycardia from Beta Blockers, Hyperkalemia, and Renal Failure. J Emerg Med. 2019 Aug;57(2):e41-e44. doi: 10.1016/j.jemermed.2019.03.039. Epub 2019 May 30. PMID: 31155316.
Wung SF. Bradyarrhythmias: Clinical Presentation, Diagnosis, and Management. Crit Care Nurs Clin North Am. 2016 Sep;28(3):297-308. doi: 10.1016/j.cnc.2016.04.003. Epub 2016 Jun 22. PMID: 27484658.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

Podcast 873: Intravesical Tranexamic Acid for Gross Hematuria Oct 16, 2023

Show notes

Contributor: Aaron Lessen MD

Educational Pearls:

Tranexamic acid (TXA) is a common medication to achieve hemostasis in a variety of conditions
Patients visiting the ED for gross hematuria (between March 2022 and September 2022) were treated with intravesical TXA

1 g tranexamic acid in 100 mL NS via Foley catheter
Clamped Foley for 15 minutes
Subsequent continuous bladder irrigation, as is standard in most EDs

Compared with a cohort of patients visiting the ED for a similar concern between March 2021 and September 2021, the TXA patients had:

A shorter median length of stay in the ED (274 min vs. 411 mins, P
A shorter median duration of Foley catheter placement (145 min vs. 308 mins, P
Fewer revisits after ED discharge (2.3% vs. 12.3%, P = 0.031)

References

1. Choi H, Kim DW, Jung E, et al. Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study. Am J Emerg Med. 2023;68:68-72. doi:10.1016/j.ajem.2023.03.020

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

Podcast 872: Preseptal and Orbital Cellulitis Oct 09, 2023

Show notes

Contributor: Meghan Hurley MD

Educational Pearls:

What is Cellulitis?

A common and potentially serious bacterial skin infection.
Caused by various types of bacteria, with Streptococcus and Staphylococcus species being the most common.

What is Preseptal Cellulitis and why is it more serious than facial cellulitis?

Preseptal Cellulitis, also known as Periorbital Cellulitis, is a bacterial infection of the soft tissues in the eyelid and the surrounding area.
This requires prompt and aggressive treatment to avoid progression into Orbital Cellulitis.

How is Preseptal Cellulitis treated?

Oral antibiotics for five to seven days.
In the setting of trauma (scratching bug bites) Clindamycin or TMP-SMX (for MRSA coverage) and Amoxicillin-clavulanic acid or Cefpodoxime or Cefdinir.
If there is no trauma, monotherapy with amoxicillin-clavulanic acid is appropriate.
Check immunization status against H.influenzae and adjust appropriately.

What is Orbital Cellulitis, how is it diagnosed, and why is it more serious than Preseptal Cellulitis?

Orbital cellulitis involves the tissues behind the eyeball and within the eye socket itself.
Key features include:

Eye pain.
Proptosis (Bulging of the eye out of its normal position).
Impaired eye movement.
Blurred or double vision.

This can lead to three very serious complications:

Orbital Compartment Syndrome. This can push eye forward, stretch optic nerve, and threaten vision.
Meningitis given that the meninges of the brain are continuous with optic nerve.
Endophthalmitis, which is inflammation of the inner coats of the eye. This can also threaten vision.

If suspected, get a CT of the orbits and/or an MRI to look for an abscess behind the eyes.

How is Orbital Cellulitis treated?

IV antibiotics. Cover for meningitis with Ceftriaxone and Vancomycin.
Add Metronidazole until intracranial involvement has been ruled out.
Drain the abscess surgically. Usually this is performed by an ophthalmologist or an otolaryngologist.
Admit to the hospital.

References

Bae C, Bourget D. Periorbital Cellulitis. 2023 Jul 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261970.
Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Al-Anezi F, Arat YO, Holck DE. Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East. Ophthalmology. 2007 Feb;114(2):345-54. doi: 10.1016/j.ophtha.2006.07.059. PMID: 17270683.
Seltz LB, Smith J, Durairaj VD, Enzenauer R, Todd J. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011 Mar;127(3):e566-72. doi: 10.1542/peds.2010-2117. Epub 2011 Feb 14. PMID: 21321025.
Wong SJ, Levi J. Management of pediatric orbital cellulitis: A systematic review. Int J Pediatr Otorhinolaryngol. 2018 Jul;110:123-129. doi: 10.1016/j.ijporl.2018.05.006. Epub 2018 May 8. PMID: 29859573.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

Mental Health Monthly #17: Mania Oct 05, 2023

Show notes

Contributors:

Andrew White MD - Outpatient Psychiatrist; Fellowship Trained in Addiction Psychiatry; Denver Health

Travis Barlock MD - Emergency Medicine Physician; Swedish Medical Center

Summary

In this episode of Mental Health Monthly, Dr. Travis Barlock hosts Dr. Andrew White to discuss the elements of mania that may be encountered in the emergency department. The discussion includes a helpful mnemonic to assess mania, work-up and treatment in the ED, underlying causes of mania, mental health holds, inpatient treatment, and the role of sleep in mania.

Educational Pearls

Initial assessment of suspected mania can be done via DIGFAST:

Distractibility - Individual that is unable to carry a linear, goal-directed conversation
Impulsivity - Executive functioning is impaired and patients are unable to control their behaviors
Grandiosity - Elevated mood and sense of self to delusions of grandeur
Flight of ideas - Usually described as racing thoughts
Agitation - Increase in psychomotor activity; start several projects of which they have little previous knowledge
Sleep decrease - Typically, manic episodes start with insomnia and can devolve into multiday sleeplessness
Talkativeness - More talkative than usual with pressured speech and a tangential thought process

Interviewing patients requires an understanding of mood-based mania vs. psychosis-based mania

An individual with mood-based mania will more likely be restless, whereas a patient with psychosis-based mania will be more relaxed from a psychomotor standpoint

Treatment of manic patients in the ED includes the use of antipsychotics to manage acute symptomatology

Management can be informed and directed by the patient's history i.e. known medications that have worked for the patient

ED management of manic patients involves a work-up for a broad differential including agitated delirium, substance-induced mania, metabolic disorders, and autoimmune diseases.
Some individuals experience manic episodes from marijuana and other illicit substances
Antidepressants used in bipolar patients for suspected depression may induce mania

Important to avoid using antidepressants as first-line therapy

Mental health holds can be beneficial in patients with grave disabilities from mania

Oftentimes, undertreatment of manic episodes leads to re-hospitalization

Inpatient treatment:

Environment is important - ensure that patients get solo rooms if possible to minimize stimulation
Antipsychotics, including risperidone and olanzapine, with or without a benzodiazepine, are useful for short-term agitation
Long-term treatment involves coupled pharmacological treatments with non-pharmacological treatments

Sleep

Fractured sleep is one of the earliest warning signs that someone has an imminent manic episode
Poor sleep can be an inciting factor for mania, which then turns into a cycle that further propagates a patient's manic episode

Summarized and edited by Jorge Chalit, OMSII | Studio production by Jeffrey Olson, MS2

Podcast 871: Increased Intracranial Pressure and the Cushing Reflex Oct 02, 2023

Show notes

Contributor: Travis Barlock MD

Education Pearls:

The Cushing Reflex is a physiologic response to elevated intracranial pressure (ICP)

Cushing's Triad: widened pulse pressure (systolic hypertension), bradycardia, and irregular respirations

Increased ICP results from systolic hypertension, which causes a parasympathetic reflex to drop heart rate, leading to Cushing's Triad.
The Cushing Reflex is a sign of herniation
Treatment includes:

Hypertonic saline is comparable to mannitol and preferable in patients with hypovolemia or hyponatremia

Give 250-500mL of 3%NaCl

20% Mannitol - given at a dose of 0.5-1 g/kg

Each additional dose of 0.1 g/kg reduces ICP by 1 mm Hg

23.4% hypertonic saline is more often given in the neuro ICU
8.4% Sodium bicarbonate lowers ICP for 6 hours without causing metabolic acidosis

Non-pharmacological interventions:

Raise the head of the bed to 30-45 degrees
Remove the c-collar to improve blood flow to the head
Hyperventilation induces hypocapnia, which will vasoconsrict the cerebral arterioles
You hyperventilate on the way to the OR. Otherwise, maintain normocapnia.

References

Alnemari AM, Krafcik BM, Mansour TR, Gaudin D. A Comparison of Pharmacologic Therapeutic Agents Used for the Reduction of Intracranial Pressure After Traumatic Brain Injury. World Neurosurg. 2017;106:509-528. doi:10.1016/j.wneu.2017.07.009
Bourdeaux C, Brown J. Sodium bicarbonate lowers intracranial pressure after traumatic brain injury. Neurocrit Care. 2010;13(1):24-28. doi:10.1007/s12028-010-9368-8
Dinallo S, Waseem M. Cushing Reflex. [Updated 2023 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549801/
Godoy DA, Seifi A, Garza D, Lubillo-Montenegro S, Murillo-Cabezas F. Hyperventilation therapy for control of posttraumatic intracranial hypertension. Front Neurol. 2017;8(JUL):1-13. doi:10.3389/fneur.2017.00250

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

On The Streets #15: Hydrofluoric Acid Case Review Sep 29, 2023

Show notes

Contributors:

Kalen Abbott, MD - EM Physician and Medical Director for AirLife Denver
Brendan Reiss - Flight Nurse AirLife Denver
Matt Spoon - Flight Paramedic AirLife Denver
Jordan Ourada - EMS Coordinator at Swedish Medical Center and Paramedic

Summary:

In this episode, hosted by Jordan Ourada, Brendan Reiss and Matt Spoon present a first-hand experience case of hydrofluoric acid exposure in a pediatric patient. Commentary and educational pearls are provided by EM Physician, Kalen Abbott.

The case:

The patient was a male infant who had spilled a large amount of heavy-duty acid aluminum wheel cleaner on himself while playing in his parent's garage. Unclear if he had ingested any fluid. The cleaning fluid contained a large percentage of hydrofluoric acid.
He was brought by EMS to his local hospital, who quickly decided to transport the infant by helicopter to a large Denver hospital.
Initial labs were unremarkable and the EKG was normal. Heart rate was in the 140s. Blood pressure was 110/73. Respirations were around 30 and non-labored. Chest and abdominal x-rays were unremarkable.
The patient had received a water-based decontamination and 1 gram of calcium gluconate IV.

Complications:

Immediately before leaving a nurse informed Brendan and Matt that the serum calcium was 6.8 mg/dl (normal range: 8.5 to 10.2).
During the flight, the patient went into cardiac arrest.
The patient achieved ROSC after CPR was administered in the helicopter.
Once on the ground, an I/O line was started and calcium chloride, sodium bicarb, and normal saline were administered.
Within the first 2 hours that patient received the equivalent of 310 mg/kg of calcium (the pediatric dose is 20 mg/kg)

Care resolution:

The patient ended up having a several-week stay in the pediatric ICU. There were some complications such as pulmonary hemorrhage. Calcium gluconate was continued via nebulization for several days. Ultimately, the child was weaned off the ventilator and spontaneous respirations resumed. They were able to wean the child off vasopressors and sedation over the course of several days. A gastric lavage with calcium gluconate was completed as well during the inpatient stay. The child was able to leave the hospital, neurologically intact after about 14 days.

Pearls:

Lower concentrations of acids can be more dangerous because they don't immediately burn but rather can be absorbed systemically through the skin.
Calcium is the antidote to hydrofluoric acid exposure.
Calcium chloride has 3 times the elemental calcium as calcium gluconate.
The maximum infusion rate of calcium chloride through a peripheral line is 1 gram every 10 minutes, calcium gluconate can be infused at 1 gram every 5 minutes.
When intubating a patient with acid exposure, avoid succinylcholine because of the risk of hyperkalemia.

References

Caravati EM. Acute hydrofluoric acid exposure. Am J Emerg Med. 1988 Mar;6(2):143-50. doi: 10.1016/0735-6757(88)90053-8. PMID: 3281684.
Pepe J, Colangelo L, Biamonte F, Sonato C, Danese VC, Cecchetti V, Occhiuto M, Piazzolla V, De Martino V, Ferrone F, Minisola S, Cipriani C. Diagnosis and management of hypocalcemia. Endocrine. 2020 Sep;69(3):485-495. doi: 10.1007/s12020-020-02324-2. Epub 2020 May 4. PMID: 32367335.
Strayer RJ. Succinylcholine, rocuronium, and hyperkalemia. Am J Emerg Med. 2016 Aug;34(8):1705-6. doi: 10.1016/j.ajem.2016.05.039. Epub 2016 May 19. PMID: 27241569.
Vallentin MF, Granfeldt A, Meilandt C, Povlsen AL, Sindberg B, Holmberg MJ, Iversen BN, Mærkedahl R, Mortensen LR, Nyboe R, Vandborg MP, Tarpgaard M, Runge C, Christiansen CF, Dissing TH, Terkelsen CJ, Christensen S, Kirkegaard H, Andersen LW. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021 Dec 14;326(22):2268-2276. doi: 10.1001/jama.2021.20929. PMID: 34847226; PMCID: PMC8634154.

Summarized by Jeffrey Olson MS2 | Edited by Jeffrey Olson, Meg Joyce, & Jorge Chalit, OMSII

Episode 870: Advanced Trauma Life Support (ATLS) Sep 25, 2023

Show notes

Contributor: Meghan Hurley MD

Educational Pearls:

What is ATLS?

Advanced Trauma Life Support (ATLS) is a systematic and comprehensive approach to the evaluation and management of trauma patients
It was developed by the American College of Surgeons (ACS)
The key components include the Primary Survey ("ABCDE"), the Secondary Survey, Definitive Care, and Special Considerations

What are the issues with ATLS?

ATLS relies on many algorithms and rules-of-thumb, which might be helpful for individuals with basic skills and training but might actually present obstacles for those with higher levels of training. Dr. Hurley cites several examples.

Example 1: ABC approach to trauma patients

ABC stands for Airway, Breathing, and Circulation but focusing on the airway first is not always the best decision.
Immediate attention may need to be applied to massive hemorrhage.
Intubating a patient that is hemodynamically unstable may cause cardiac arrest.
A more helpful phrase might be "Resuscitate before you intubate."

Example 2: C-spine precautions

Cervical collars may impede the likelihood of first-pass success when intubating. The risk of complications from a failed airway may often outweigh the risk of causing a spinal cord injury.

Example 3:Cutting clothes off.

The E of ABCDE stands for exposure which means fully undressing the patient to look for missing injuries. This often involves cutting their clothes off.
This practice might be too broadly applied and leave low-risk trauma patients without any clothes to wear when discharged home.

Example 4: Digital rectal exam

A rectal exam can be a useful tool in the evaluation of patients with abdominal or pelvic injuries. It can help screen for rectal bleeding, pelvic fractures, and neurological function
However, the rectal exam is not a sensitive test. A retrospective study from the Indian Journal of Surgery found that a rectal exam missed 100% of urethra injuries, 92% of spinal cord injuries, 93% of small bowel injuries, 100% of colon injuries, and 67% of rectal injuries in trauma patients.

Example 6: Pushing on pelvis for pelvic injuries

Pushing on the pelvis to check for instability can cause further damage to an unstable pelvis. Imaging the pelvis is far more important than pressing on it if a pelvic fracture is suspected.

Example 7: FAST exam

A FAST exam, which stands for "Focused Assessment with Sonography for Trauma," is a rapid ultrasound examination used to assess trauma patients for signs of internal bleeding or organ damage in the abdomen and chest.
These can be very useful as an initial test to tell a trauma surgeon where to start looking for internal bleeding in an unstable blunt traumatic injury
If a patient is stable and likely going to get a CT scan whether the FAST is positive or negative then the test is unnecessary

References

ATLS Subcommittee; American College of Surgeons' Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013 May;74(5):1363-6. doi: 10.1097/TA.0b013e31828b82f5. PMID: 23609291.
Bloom BA, Gibbons RC. Focused Assessment With Sonography for Trauma. 2023 Jul 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261902.
Brown R. Oxygenate and Resuscitate Before You Intubate. Common pitfalls to avoid when managing the crashing airway. EMS World. 2016 Jan;45(1):48-50, 52, 54-5. PMID: 26852546.
Chrimes N, Marshall SD. Attempt XYZ: airway management at the opposite end of the alphabet. Anaesthesia. 2018 Dec;73(12):1464-1468. doi: 10.1111/anae.14361. Epub 2018 Jul 11. PMID: 29998563.
Docimo S Jr, Diggs L, Crankshaw L, Lee Y, Vinces F. No Evidence Supporting the Routine Use of Digital Rectal Examinations in Trauma Patients. Indian J Surg. 2015 Aug;77(4):265-9. doi: 10.1007/s12262-015-1283-y. Epub 2015 May 19. PMID: 26702232; PMCID: PMC4688269.
Groeneveld A, McKenzie ML, Williams D. Logrolling: establishing consistent practice. Orthop Nurs. 2001 Mar-Apr;20(2):45-9. doi: 10.1097/00006416-200103000-00011. PMID: 12024634.
Morgenstern, J. The FAST exam: overused and overrated?, First10EM, August 30, 2021.
Rodrigues IFDC. To log-roll or not to log-roll - That is the question! A review of the use of the log-roll for patients with pelvic fractures. Int J Orthop Trauma Nurs. 2017 Nov;27:36-40. doi: 10.1016/j.ijotn.2017.05.001. Epub 2017 May 10. PMID: 28797555.
Sapsford W. Should the 'C' in 'ABCDE' be altered to reflect the trend towards hypotensive resuscitation? Scand J Surg. 2008;97(1):4-11; discussion 12-3. doi: 10.1177/145749690809700102. PMID: 18450202.
Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma. 2014 Mar 15;31(6):531-40. doi: 10.1089/neu.2013.3094. Epub 2013 Nov 6. PMID: 23962031; PMCID: PMC3949434.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

Podcast 869: Shift Work Sep 18, 2023

Show notes

Contributor: Meghan Hurley MD

Educational Pearls:

Shift work is defined as anything that takes place outside of a 9-5 schedule, not exempting day-shift medical workers
Various ill effects of shift work on overall health:

Increased all-cause mortality
Increased number of accidents
Glucose metabolism dysregulation
Increased BMI
Fertility impacts for men and women
Increased breast cancer risk
Decreased cognitive functioning

Mitigation strategies

Work at the same time every day
Anchor Sleep - always try to be asleep at the same time of day
Progressive shifts: day- into swing- into night shift instead of the other way around
Three days off after a stretch of nights can help reset sleep schedule
Shorter night shifts
Morning shifts should start no earlier than 8 AM

Sleep hygiene

Ensure an ideal sleep environment; cool, dark, and damp
Avoid bright lights when going to sleep
Exposure to bright lights when waking up
Hydration throughout your shift
Stop caffeine at midnight if you are working a night shift
Eat healthy meals and avoid junk food
Avoid eating 2-3 hours before going to sleep

References

Boivin, D. B., Boudreau, P., & Kosmadopoulos, A. (2022). Disturbance of the Circadian System in Shift Work and Its Health Impact. Journal of biological rhythms, 37(1), 3–28. https://doi.org/10.1177/07487304211064218
Jang TW. Work-Fitness Evaluation for Shift Work Disorder. Int J Environ Res Public Health. 2021;18(3):1294. Published 2021 Feb 1. doi:10.3390/ijerph18031294
Minors DS, Waterhouse JM. Anchor sleep as a synchronizer of rhythms on abnormal routines. Int J Chronobiol. 1981;7(3):165-188.
Reinganum MI, Thomas J. Shift Work Hazards. [Updated 2023 Jan 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589670/

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

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