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 868: Airway Management in Obesity Sep 11, 2023

Show notes

Contributor: Aaron Lessen MD

Educational Pearls:

Why is airway management more difficult in obesity?

Larger body habitus causes the chest to be above the head when the patient is lying supine, creating difficult angles for intubation.
Reduced Functional Residual Capacity (FRC) causes these patients to deoxygenate much more quickly, reducing the amount of time during which the intubation can take place.

What special considerations need to be made?

Positioning. The auditory canal and sternal notch should be aligned in a horizontal plane. Do this by stacking blankets to lift the neck and head. Also, try to make the head itself parallel to the ceiling.
Pre-oxygenation. Use Bi-level Positive Airway Pressure (BiPAP) with Positive End Expiratory Pressure (PEEP) or a Bag-Valve-Mask (BVM) with a PEEP valve. PEEP helps prevent alveoli from collapsing after every breath and improves oxygenation.
Dosing of paralytics. Succinylcholine is dosed on total body weight so the dose will be much larger for the obese patient. Rocuronium is dosed on ideal body weight, but adjusted body weight may also be used in obese cases.

References

De Jong A, Wrigge H, Hedenstierna G, Gattinoni L, Chiumello D, Frat JP, Ball L, Schetz M, Pickkers P, Jaber S. How to ventilate obese patients in the ICU. Intensive Care Med. 2020 Dec;46(12):2423-2435. doi: 10.1007/s00134-020-06286-x. Epub 2020 Oct 23. PMID: 33095284; PMCID: PMC7582031.
Langeron O, Birenbaum A, Le Saché F, Raux M. Airway management in obese patient. Minerva Anestesiol. 2014 Mar;80(3):382-92. Epub 2013 Oct 14. PMID: 24122033.
Sharma S, Arora L. Anesthesia for the Morbidly Obese Patient. Anesthesiol Clin. 2020 Mar;38(1):197-212. doi: 10.1016/j.anclin.2019.10.008. Epub 2020 Jan 2. PMID: 32008653.
Singer BD, Corbridge TC. Basic invasive mechanical ventilation. South Med J. 2009 Dec;102(12):1238-45. doi: 10.1097/SMJ.0b013e3181bfac4f. PMID: 20016432.

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

Episode 867: Occult Scaphoid Fractures Sep 04, 2023

Show notes

Contributor: Nick Tsipis MD

Educational Pearls:

The scaphoid bone is the most proximal carpal bone just distal to the radius
Fractures of the scaphoid bone are sometimes missed by plain X-rays

A 2020 review found a 21.8% incidence of missed scaphoid fractures later diagnosed by advanced imaging modalities
Only MRI has a sensitivity above 90% for diagnosing scaphoid fractures
Sensitivity of plain-film radiography is low unless it is a displaced fracture

Physical examination techniques fail to definitively rule out scaphoid fractures
A 2023 systematic review assessed the sensitivity and specificity of several common physical exam maneuvers:

Tenderness of the anatomical snuffbox has a sensitivity of 92.1% and specificity of 48.4%; i.e. absence reduces the likelihood of an occult scaphoid fracture but does not rule it out
Another common physical exam maneuver is pain with ulnar deviation, which carries a sensitivity of 55.2% and specificity of 76.4%.
Elicitation of pain with supination against resistance demonstrated a sensitivity of 100% and specificity of 97.9% in the study, so the authors recommend externally validating this method

Patients should be counseled on the importance of follow-up given that a fracture may not show up on imaging unless an MRI or repeat XR is done

References

1. Bäcker HC, Wu CH, Strauch RJ. Systematic Review of Diagnosis of Clinically Suspected Scaphoid Fractures. J Wrist Surg. 2020;09(01):081-089. doi:10.1055/s-0039-1693147

2. Coventry L, Oldrini I, Dean B, Novak A, Duckworth A, Metcalfe D. Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies. Emerg Med J. 2023;40(8):576 LP - 582. doi:10.1136/emermed-2023-213119

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

Podcast 866: Carbamazepine (Tegretol) Overdose Aug 28, 2023

Show notes

Contributor: Aaron Lessen MD

Educational Pearls:

What is Carbamazepine (Tegretol)?

Carbamazepine is an anti-epileptic drug with mood-stabilizing properties that is used to treat bipolar disorder, epilepsy, and neuropathic pain.
It functions primarily by blocking sodium channels which can prevent repetitive action potential firing.

What are the symptoms of an overdose?

Common initial signs include diminished conscious state, nystagmus, ataxia, hyperreflexia, CNS depression, dystonia, and tachycardia
Severe toxicity can cause seizures, respiratory depression, decreased myocardial contractility, pulmonary edema, hypotension, and dysrhythmias.

How is an overdose treated?

An overdose is treated with large doses of activated charcoal and correction of electrolyte disturbances.
Be ready to intubate given the potential for respiratory depression.
Carbamazepine is moderately dialyzable and dialysis is recommended in severe overdoses.

Additional educational pearl: Individuals in correctional facilities can occasionally self-administer medications which means that medication overdose should still be on the differential for any of these individuals.

References

Epilepsies in children, Young People and adults: NICE guideline [NG217]. National Institute for Health and Care Excellence. (2022, April 27). https://www.nice.org.uk/guidance/ng217
Ghannoum M, Yates C, Galvao TF, Sowinski KM, Vo TH, Coogan A, Gosselin S, Lavergne V, Nolin TD, Hoffman RS; EXTRIP workgroup. Extracorporeal treatment for carbamazepine poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2014 Dec;52(10):993-1004. doi: 10.3109/15563650.2014.973572. Epub 2014 Oct 30. PMID: 25355482; PMCID: PMC4782683.
Seymour JF. Carbamazepine overdose. Features of 33 cases. Drug Saf. 1993 Jan;8(1):81-8. doi: 10.2165/00002018-199308010-00010. PMID: 8471190.
Spiller HA. Management of carbamazepine overdose. Pediatr Emerg Care. 2001 Dec;17(6):452-6. doi: 10.1097/00006565-200112000-00015. PMID: 11753195.
Tran NT, Pralong D, Secrétan AD, Renaud A, Mary G, Nicholas A, Mouton E, Rubio C, Dubost C, Meach F, Bréchet-Bachmann AC, Wolff H. Access to treatment in prison: an inventory of medication preparation and distribution approaches. F1000Res. 2020 May 13;9:357. doi: 10.12688/f1000research.23640.3. PMID: 33123347; PMCID: PMC7570324.

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

Laboring Under Pressure- Episode 1. ACLS in Pregnancy with Dr. Jason Papazian Aug 24, 2023

Show notes

Contributor: Jason Papazian MD, Travis Barlock MD, Jeffrey Olson

Summary:

In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss several clips from Dr. Jason Papazian's talk at the event "Laboring Under Pressure, Managing Obstetric Emergencies in a Global Setting" from May 2023. This event was hosted at the University of Denver and was organized with the help of Joe Parker as a fundraiser for the organization Health Outreach Latin America (HOLA).

Dr. Jason Papazian practices Obstetric Anesthesiology for the Maternal Fetal Care Unit at Children's Hospital Colorado. He is the Assistant Program Director of Didactics for the Anesthesiology Residency at the University of Colorado, as well as the Faculty Advisor to Residents and Obstetric Anesthesiology Fellows.

During his talk, Dr. Papazian walks the audience through the steps of a maternal cardiac arrest from initial rapid response, to intubation, CPR, ACLS, and eventually emergency cesarean section.

Some important take-away points from this talk are:

The basics save lives. Focus on oxygenating the patient and providing high quality CPR
In order to maximize blood return during CPR on an obstetric patient, manually retract the gravid uterus to the left
If an arresting mother does not obtain return of spontaneous circulation (ROSC) by 4 minutes, the most qualified person should perform a rapid 1-minute bedside cesarean section. This has mortality benefits for both the mother and the infant.

Other medical topics discussed include changes in the obstetric patient's physiology, roles during a rapid response, steps of intubation, causes of cardiac arrest, management of cardiac arrest, and how pregnancy does (and doesn't) change ACLS.

References

Bennett TA, Katz VL, Zelop CM. Cardiac Arrest and Resuscitation Unique to Pregnancy. Obstet Gynecol Clin North Am. 2016 Dec;43(4):809-819. doi: 10.1016/j.ogc.2016.07.011. PMID: 27816162.
Campbell TA, Sanson TG. Cardiac arrest and pregnancy. J Emerg Trauma Shock. 2009 Jan;2(1):34-42. doi: 10.4103/0974-2700.43586. PMID: 19561954; PMCID: PMC2700584.
Health Outreach for Latin America Foundation - HOLA Foundation. (n.d.). http://www.hola-foundation.org/
Kikuchi J, Deering S. Cardiac arrest in pregnancy. Semin Perinatol. 2018 Feb;42(1):33-38. doi: 10.1053/j.semperi.2017.11.007. Epub 2017 Dec 13. PMID: 29246735.

Produced by Jeffrey Olson, MS2 | Edited by Jeffrey Olson and Jorge Chalit, OMSII

*********************

Podcast 865: Nausea Treatments - Droperidol vs Ondansetron RCT Aug 21, 2023

Show notes

Contributor: Aaron Lessen MD

Educational Pearls:

A recent randomized controlled trial compared ondansetron 8 mg IV with droperidol 2.5 mg IV for the treatment of nausea & vomiting in the emergency department.
Overall, droperidol and ondansetron had similar primary outcomes in acute nausea control

Symptom improvement in 93% of patients receiving droperidol vs. 87% receiving ondansetron (P = 0.362)

Secondary measures were, however, statistically significantly different between groups

Patients needed fewer rescue/additional antiemetics in the droperidol group (16%) compared with the ondansetron group (37%); p = 0.016
Similarly, more patients in the droperidol group reported they achieved the desired effect of the medication (85% vs. 63%; p = 0.006)

Patients receiving droperidol did experience increased drowsiness

40% in the droperidol group vs. 11% in the ondansetron group

The trial did not assess the length of stay in the ED after administering medications, which is a potential avenue for future research.

References

1. Philpott L, Clemensen E, Lau GT. Droperidol versus ondansetron for nausea treatment within the emergency department. EMA - Emerg Med Australas. 2023;(December 2022):605-611. doi:10.1111/1742-6723.14174

Summarized & Edited by Jorge Chalit, OMSII

Podcast 864: Arterial Blood Gas (ABG) vs Venous Blood Gas (VBG) Aug 14, 2023

Show notes

Contributor: Aaron Lessen MD

Educational Pearls:

What is measured in an ABG/VBG?

Blood values for oxygen tension (pO2), carbon dioxide tension (pCO2), acidity (pH), oxyhemoglobin saturation, and bicarbonate (HCO3) in either arterial or venous blood
Other tests can measure methemoglobin, carboxyhemoglobin, hemoglobin levels, base excess, and lactate

What are they used for?

Identification of ventilation/acid-base disturbances. For example: if a patient is in septic shock, oxyhemoglobin saturation can be used to guide resuscitation efforts (early goal- directed therapy)

What's the difference between an ABG and VBG?

One of the main differences is how the blood samples are collected. Venous blood gas is normally collected from existing venous access such as a central venous catheter. Arterial blood gases must be drawn from an artery, such as the radial artery.
Arterial blood draws can be difficult, painful, and contraindicated in many situations.
ABGs have traditionally provided more accurate measurements for assessing oxygenation, ventilation, and acid-base status.
However, several studies have found that VBGs can still be used to accurately assess pH, pCO2, HCO3, lactate, sodium, potassium, chloride, ionized calcium, blood urea nitrogen, base excess, and arterial/alveolar oxygen ratio. This is supported by a recent study in 2023 in the International Journal of Emergency Medicine which specifically studied patients with hypotension and use of VBGs for resuscitation guidance.

Are there other non-invasive methods that can be used to fill in the gaps to avoid ordering an ABG?

Oxygenation can be measured by pulse oximetry
Arterial carbon dioxide tension can be estimated by end-tidal carbon dioxide (PetCO2)
Mixed venous blood gases are another alternative for patients who already have a pulmonary artery catheter

References

Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77. doi: 10.1056/NEJMoa010307. PMID: 11794169.
Prasad H, Vempalli N, Agrawal N, Ajun UN, Salam A, Subhra Datta S, Singhal A, Ranjan N, Shabeeba Sherin PP, Sundareshan G. Correlation and agreement between arterial and venous blood gas analysis in patients with hypotension-an emergency department-based cross-sectional study. Int J Emerg Med. 2023 Mar 10;16(1):18. doi: 10.1186/s12245-023-00486-0. PMID: 36899297; PMCID: PMC9999648.

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

Podcast 863: Treatments for Alcohol Use Disorder Aug 07, 2023

Show notes

Contributor: Aaron Lessen MD

Educational Pearls:

Patients with alcohol use disorder are frequently discharged from the ED without further resources
Pharmacological treatments to reduce cravings in AUD exist
Naltrexone

Effective at reducing alcohol cravings and heavy drinking

Gabapentin

Reduces the percentage of heavy drinking days in AUD

Patients being discharged from the ED should be asked if they feel their alcohol use is a problem, which can further direct appropriate pharmacological interventions

References

1. Kranzler M.D. HR, Feinn Ph.D. R, Morris B.A. P, Hartwell Ph.D. EE. A Meta-analysis of the Efficacy of Gabapentin for Treating Alcohol Use Disorder Henry. Addiction. 2019;114(9):1547-1555. doi:10.1111/add.14655

2. Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: When are these medications most helpful? Addiction. 2013;108(2):275-293. doi:10.1111/j.1360-0443.2012.04054.x

3. Mariani JJ, Pavlicova M, Basaraba C, et al. Pilot randomized placebo-controlled clinical trial of high-dose gabapentin for alcohol use disorder. Alcohol Clin Exp Res. 2021;45(8):1639-1652. doi:10.1111/acer.14648

Summarized & Edited by Jorge Chalit, OMSII

Podcast 862: How to Apply a Painful Stimulus Jul 31, 2023

Show notes

Contributor: Travis Barlock MD

Educational Pearls:

When might you need to apply a painful stimulus in a medical setting?

The main reason is to assess the patient's level of consciousness, such as when they are waking up from anesthesia or have potentially suffered a brain injury.
It can be part of the Glasgow Coma Scale (GCS) if patients are not responding to auditory stimuli.
Possible levels of consciousness include Alert, Lethargic, Obtunded, and Comatose (ALOC)

What are the approved ways to apply a painful stimulus to assess central nervous system function?

Trapezius squeeze. Grab the trapezius muscle and twist (contraindicated in clavicle fractures).
Supraorbital rim pressure. Find the notch in the supraorbital rim of the patient and push hard with your thumb (contraindicated in facial fractures).
Mandibular pressure (not mentioned). Press hard at the angle of the jaw on the mandibular nerve (contraindicated in mandible fractures).
Sternal rub. Push down with your knuckles into the patient's sternum and rub vigorously (contraindicated in chest injury/surgery).
Each technique should be done for between 15 and 30 seconds.
If skin damage is observed in one location, move to a different location. This is especially true of the sternal rub.

Important note: Peripheral techniques such as nail tip pressure should only be used to evaluate spinal nerve reflexes and not as a method of assessing the level of consciousness.

References

Lower J. Using pain to assess neurologic response. Nursing. 2003 Jun;33(6):56-7. doi: 10.1097/00152193-200306000-00047. PMID: 12799591.
Middleton PM. Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology. Australas Emerg Nurs J. 2012 Aug;15(3):170-83. doi: 10.1016/j.aenj.2012.06.002. Epub 2012 Aug 3. PMID: 22947690.
Mistovich JJ, Krost W, Limmer DD. Beyond the basics: patient assessment. Emerg Med Serv. 2006 Jul;35(7):72-7; quiz 78-9. PMID: 16878751.
Naalla R, Chitirala P, Chittaluru P, Atreyapurapu V. Sternal rub causing presternal abrasion in a patient with capsuloganglionic haemorrhage. BMJ Case Rep. 2014 Apr 7;2014:bcr2014204028. doi: 10.1136/bcr-2014-204028. PMID: 24711478; PMCID: PMC3987201.

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

Podcast 861: Alcohol Withdrawal and Delirium Tremens Jul 24, 2023

Show notes

Contributor: Travis Barlock MD

Educational Pearls:

Alcohol binds the GABA receptor, which produces an inhibitory response, hence the "depressive" effects of ethanol beverages.
Over time, alcohol downregulates the GABA receptors, leading to unopposed glutamate activity. Given that glutamate is excitatory, this can lead to seizures.
Alcohol also suppresses REM sleep; in patients with chronically suppressed REM sleep, the brain starves for dream sleep and it spills over into the wakeful state, inducing a dream-like state when someone is awake.
The awake dream-like state of delirium tremens (DT) differs from alcohol hallucinosis

Alcohol hallucinosis presents with visual hallucinations in a wakeful state
DT presents with a generalized clouding of the sensorium and a dream-like state

Treatment for DT is better achieved with phenobarbital due to predictable pharmacology

Phenobarbital acts on GABA and NMDA receptors

References

1. Davies M. The role of GABAA receptors in mediating the effects of alcohol in the central nervous system. J Psychiatry Neurosci. 2003;28(4):263-274.

2. Fujimoto J, Lou JJ, Pessegueiro AM. Use of Phenobarbital in Delirium Tremens. J Investig Med High Impact Case Reports. 2017;5(4):4-6. doi:10.1177/2324709617742166

3. Walker, M. Chapter 13: iPads, Factory Whistles, and Nightcaps In: Walker, M, Why We Sleep. Scribner; 2017, pg. 272.

4. Zarcone V. Alcoholism and sleep. Adv Biosci. 1978;21:29-38.

Summarized & Edited by Jorge Chalit, OMSII

Ukraine Brewtalk Featuring Dr. Dave Young Jul 21, 2023

Show notes

Contributors: David Young MD, John Hesling MD, Travis Barlock MD, Jeffrey Olson

Summary:

In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss several clips from the event "Ukraine Brewtalk" from October 2022. This event was hosted by the University of Colorado's Center for COMBAT Research and Emergency Medical Minute assisted in the audio recording of the speakers.

The first clip is of a brief talk by Dr. John Hesling who was presenting some of his research about Pediatric Supermassive Transfusions.

The second and third clips are from the keynote speaker, Dr. Dave Young, an Emergency Medicine Physician at the University of Colorado Hospital, talking about his experience of serving with USA's Team Rubicon providing medical aid in war-torn Ukraine.

Medical topics discussed include Pediatric trauma, blood transfusions, tourniquet use, refugee care, and blast injuries.

References

Hesling JD, Paulson MW, McKay JT, Bebarta VS, Flarity K, Keenan S, Fisher AD, Borgman MA, April MD, Schauer SG. Characterizing pediatric supermassive transfusion and the contributing injury patterns in the combat environment. Am J Emerg Med. 2022 Jan;51:139-143. doi: 10.1016/j.ajem.2021.10.032. Epub 2021 Oct 24. Erratum in: Am J Emerg Med. 2022 Feb;52:275. PMID: 34739866.
UNHCR. (2023, July 11). Ukraine Refugee Situation. Operational Data Portal. https://data2.unhcr.org/en/situations/ukraine
Ainsley, J. (2023, February 24). U.S. has admitted 271,000 Ukrainian refugees since Russian invasion, far above Biden's goal of 100,000. NBCNews.com. https://www.nbcnews.com/politics/immigration/us-admits-271000-ukrainian-refugees-russia-invasion-biden-rcna72177
Built to serve. Team Rubicon. https://teamrubiconusa.org/

Summarized by Jeffrey Olson, MS1 | Edited by Jeffrey Olson MS1 and Jorge Chalit, OMSII

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