Emergency Medical Minute

Latest Episodes:

Podcast 860: Thyrotoxicosis Jul 20, 2023

Show notes

Contributor: Travis Barlock MD

Educational Pearls:

Clinical picture: A patient comes in with altered mental status, tachycardia, fever, elevated T4, and low TSH. What's the diagnosis?... Thyrotoxicosis secondary to Graves' Disease.

How do you treat thyrotoxicosis?

First, give a beta-blocker such as propranolol. This suppresses the elevated adrenergic activity.
Second, give a thionamide such as propylthiouracil (PTU) or methimazole. This decreases the synthesis of new thyroid hormone. PTU is preferred because it also blocks the conversion of T4 to T3.
Third, give an iodine solution such as potassium iodide. This blocks the release of thyroid hormone through a mechanism called the Wolff-Chaikoff effect. Note, this should be given about an hour after the PTU/methimazole to ensure iodine cannot be taken up and used to synthesize more thyroid hormone in individuals with toxic adenoma or toxic multinodular goiter.
Fourth, give a glucocorticoid such as hydrocortisone. This will reduce thyroid hormone conversion from T4 to T3 and treat any concurrent adrenal insufficiency.

References

Abuid J, Larsen PR. Triiodothyronine and thyroxine in hyperthyroidism. Comparison of the acute changes during therapy with antithyroid agents. J Clin Invest. 1974 Jul;54(1):201-8. doi: 10.1172/JCI107744. PMID: 4134836; PMCID: PMC301541.
Cooper DS, Saxe VC, Meskell M, Maloof F, Ridgway EC. Acute effects of propylthiouracil (PTU) on thyroidal iodide organification and peripheral iodothyronine deiodination: correlation with serum PTU levels measured by radioimmunoassay. J Clin Endocrinol Metab. 1982 Jan;54(1):101-7. doi: 10.1210/jcem-54-1-101. PMID: 6274892.
Das G, Krieger M. Treatment of thyrotoxic storm with intravenous administration of propranolol. Ann Intern Med. 1969 May;70(5):985-8. doi: 10.7326/0003-4819-70-5-985. PMID: 5769631.
Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii. doi: 10.1016/j.ecl.2006.09.008. PMID: 17127140.
Tsatsoulis A, Johnson EO, Kalogera CH, Seferiadis K, Tsolas O. The effect of thyrotoxicosis on adrenocortical reserve. Eur J Endocrinol. 2000 Mar;142(3):231-5. doi: 10.1530/eje.0.1420231. PMID: 10700716.

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

Podcast 859: Teamwork Really Makes the Dream Work Jul 10, 2023

Show notes

Contributor: Aaron Lessen MD

Educational Pearls:

33 Medical residents and 91 nurses at Massachusetts General Hospital were randomized into two groups:

Intervention group: 15 PGY-1 residents assigned to the same medical service floor for a 16-week period (12 weeks after adjustment for COVID-19 restrictions) alongside 43 nurses.
Control group: 18 PGY-1 residents assigned to the usual 4-week block rotations across 6 medical floors.

At 6 months, there were no differences in teamwork performance metrics including advanced medical simulations and nurse presence at rounds.
The 12-month assessment demonstrated improvement in performance metrics.
Increased time together allows individuals to get to know each other better and therefore improve performance metrics that rely on communication.

References

1. Iyasere CA, Wing J, Martel JN, Healy MG, Park YS, Finn KM. Effect of Increased Interprofessional Familiarity on Team Performance, Communication, and Psychological Safety on Inpatient Medical Teams: A Randomized Clinical Trial. JAMA Intern Med. 2022;182(11):1190-1198. doi:10.1001/jamainternmed.2022.4373

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

Podcast 858: Whole Blood Pregnancy Test Jul 03, 2023

Show notes

Contributor: Meghan Hurley MD

Educational Pearls:

What do you do if you need a stat pregnancy test on an incapacitated patient?

You can send a serum quantitative human chorionic gonadotropin (beta-HCG), but that might take a while for the lab to process.
Another option is to place a drop of whole blood on a urine pregnancy immunoassay.

These tests are already verified for urine and serum.
2012 study showed that whole blood was 95.8% sensitive for pregnancy compared to 95.3% for urine.
Takes a little bit longer (10 minutes was used in the study) due to the viscosity of blood.
Word of caution: This study only looked at a single urine pregnancy kit type. It is possible that other kits would have a different efficacy.

There are new finger stick tests coming out for capillary blood.
Anecdotally, Dr. Hurley was able to use this technique to support a diagnosis of ruptured ectopic pregnancy in a patient that needed emergent surgery.

References

Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776.
Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, Grenache DG. Analytical performance evaluation of the i-STAT Total β-human chorionic gonadotropin immunoassay. Clin Chim Acta. 2015 Jun 15;446:165-70. doi: 10.1016/j.cca.2015.04.025. Epub 2015 Apr 25. PMID: 25916696.

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

Podcast 857: Alice in Wonderland Jeopardy Jun 26, 2023

Show notes

Contributor: Chris Holmes MD

Educational Pearls:

"It's a poor sort of memory that only works backwards" - Transient Global Amnesia

A syndrome with sudden retrograde memory loss in which patients cannot retain new information
Characterized by perseveration in frequent intervals
Typically improves within hours
MRI is normal initially

Alice In Wonderland Syndrome

A disorder in which patients experience distortions in their visual perceptions
Most often characterized by micropsia and/or macropsia
Other symptoms may include illusory movement or wavy lines

Alice in Wonderland as a metaphor for birth

Traveling down the rabbit hole is conception
Alice getting bigger in a confined space is pregnancy
Drinking potions is amniotic fluid
Escaping to explore a scary world is childbirth

References

1. Blom JD. Alice in wonderland syndrome. Alice Wonderl Syndr. 2019;(June):1-221. doi:10.1007/978-3-030-18609-8

2. Ropper M.D. AH. Transient Global Amnesia. N Engl J Med. 2023;(388):635-640. doi:10.1056/NEJMra2213867

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

Podcast 856: ED Errors and Counterstudy Jun 19, 2023

Show notes

Contributor: Nicholas Tsipis, MD

Educational Pearls:

What study was Dr. Tsipis talking about?

In December of 2022, the Agency for Healthcare Research and Quality (AHRQ) put out a study titled "Diagnostic Errors in the Emergency Department: A Systematic Review."
This study triggered many news stories from prominent outlets with headlines such as, "More than 7 million incorrect diagnoses made in US emergency rooms every year, government report finds," from CNN, and "E.R. Doctors Misdiagnose Patients With Unusual Symptoms," from the New York Times.

What was the response?

Matt Bivens, MD from Emergency Medicine News responded to the original study in an article titled, "AHRQ Errors Report was 'Outright Unconscionable.'"
Dr. Bivens points out that AHRQ's biggest claims – including that 5.7% of patients are misdiagnosed in the ED and 2.0% suffer an adverse event as a result – were based only on three small studies out of Canada, Spain, and Switzerland (combined n=1,758).
Spain and Switzerland did not have emergency medicine residency-trained physicians at the time of the studies.
The Swiss study looked at when the diagnosis changed significantly between admittance and discharge to which Bivens responded, "Are we describing errors in this study or just an ongoing collaborative process?"
The Canadian study looked at 503 high-acuity patients of which one died of a missed aortic dissection. Bivens notes that this is too small of sample size to be generalized to the American ER population which includes a mix of low and high acuity.

Moral of the story?

Mistakes do happen in the ED and they do negatively impact patients but be careful in how you interpret studies and news articles that report on them.

References

Newman-Toker DE, Peterson SM, Badihian S, Hassoon A, Nassery N, Parizadeh D, Wilson LM, Jia Y, Omron R, Tharmarajah S, Guerin L, Bastani PB, Fracica EA, Kotwal S, Robinson KA. Diagnostic Errors in the Emergency Department: A Systematic Review. Comparative Effectiveness Review No. 258. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 75Q80120D00003.) AHRQ Publication No. 22(23)-EHC043. Rockville, MD: Agency for Healthcare Research and Quality; December 2022. DOI: 10.23970/AHRQEPCCER258.
Kounang, N. (2022, December 16). More than 7 million incorrect diagnoses made in US emergency rooms every year, government report finds. CNN. https://www.cnn.com/2022/12/15/health/hospital-misdiagnoses-study/index.html
Abelson, R. (2022, December 15). E.R. Doctors Misdiagnose Patients With Unusual Symptoms. The New York Times. https://www.nytimes.com/2022/12/15/health/medical-errors-emergency-rooms.html?searchResultPosition=3
Bivens, Matt MD. Evidence-Based Medicine: AHRQ Errors Report was 'Outright Unconscionable'. Emergency Medicine News 45(3):p 1,21, March 2023. | DOI: 10.1097/01.EEM.0000922716.51556.31

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

Podcast 855: QT Intervals Jun 12, 2023

Show notes

Contributor: Travis Barlock MD

Educational Pearls

The QT interval represents phases 2 and 3 of ventricular plateau and repolarization, respectively.

As the QT interval lengthens, more sodium and calcium channels are available and susceptible to action potentials.

Prolonged QT interval is more concerning in the setting of bradycardia.

This scenario increases the likelihood of R on T phenomenon.

R on T phenomenon occurs due to an early afterdepolarization event in which a premature ventricular contraction (PVC) occurs during the repolarization period (superimposed on the T wave), leading to an aberrant re-entry circuit.
The re-entry circuit leads to Torsades de Pointes (polymorphic ventricular tachycardia with prolonged QT) and subsequent ventricular fibrillation.
Treatment for Torsades de Pointes is 2g MgSO4.
The preferred antiarrhythmic for VTach is IV lidocaine 1.5 mg/kg over 2 minutes.

Avoid amiodarone due to risk of further QT prolongation.

A heart rate under 80 does not need QT correction

Corrected QT interval is used in the setting of tachycardia due to an abnormally small T wave

Correction for the QT interval in tachycardia:

472 ms for males vs. 482 ms for females

References

1. Banai S, Schuger C, Benhorin J, Tzivoni D. Treatment of torsade de pointes with intravenous magnesium. Am J Cardiol. 1989;63(20):1539-1540. doi:10.1016/0002-9149(89)90033-7

2. Gorgels APM, Van Den Dool A, Hofs A, et al. Comparison of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia. Am J Cardiol. 1996;78(1):43-46. doi:10.1016/S0002-9149(96)00224-X

3. Liu MB, Vandersickel N, Panfilov A V., Qu Z. R-From-T as a Common Mechanism of Arrhythmia Initiation in Long QT Syndromes. Circ Arrhythmia Electrophysiol. 2019;12(12):1-15. doi:10.1161/CIRCEP.119.007571

4. Sagie A, Larson MG, Goldberg RJ, Bengtson JR, Levy D. An improved method for adjusting the QT interval for heart rate (the Framingham Heart Study). Am J Cardiol. 1992;70(7):797-801. doi:10.1016/0002-9149(92)90562-D

5. Vandenberk B, Vandael E, Robyns T, et al. Which QT correction formulae to use for QT monitoring? J Am Heart Assoc. 2016;5(6). doi:10.1161/JAHA.116.003264

6. Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines. Vol 114.; 2006. doi:10.1161/CIRCULATIONAHA.106.178104

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

Mental Health Monthly #16: Psychosis in the ED Part II Jun 07, 2023

Show notes

Contributors: Andrew White MD & Travis Barlock MD

In this follow-up episode Dr. Andrew White, a practicing psychiatrist with an addiction medicine fellowship, and Dr. Travis Barlock, an emergency physician at Swedish Medical Center, discuss mental health holds, psychiatric placement, pharmacologic vs. non-pharmacologic treatments, and outpatient care of psychotic patients. If you missed it, be sure to listen to part I for details on the management of psychotic patients in the ED.

Educational Pearls:

Mental health holds should be approached on a case-by-case basis; this includes assessing safety risks immediately, over a 24-hour period, and chronically over the last few months. Lastly, collateral information is useful in assessing a mental health hold.

What happens after patients get placed in inpatient psychiatry? Typically an antipsychotic is started; in the absence of metabolic risks, patients will often be started on Zyprexa, especially in oral dissolvable form. Doses of Zyprexa ODT start at 2.5 - 5 mg per day.

If psychotic patients do not pose direct harm to the environment, they do not necessarily need to be medicated. However, patients will often need medication at some point; for example, some people may be calm during their psychosis but unable to feed themselves or perform other ADLs.

The goal of pharmacologic treatment for psychosis is to save the brain; each episode of psychosis damages the brain. Oftentimes, patients will be started on long-acting injectables like aripiprazole or risperidone to give patients 30 days of treatment with one shot.

Non-pharmacologic approaches to psychosis are challenging given the nature of the disease. There have been attempts at therapy for psychosis but not have not been hugely successful. Options for support include PT/OT, family support via organizations like NAMI, and other resources for families of patients with psychosis.

Outpatient care of patients with psychosis includes contextualizing the events. For example, many people who experience brief psychotic episodes do not go on to develop schizophrenia so it is important to identify a prognosis. On the other hand, someone who has worsening symptoms over several months may require more aggressive treatment.

The primary goal of outpatient management of older patients is to reduce the adverse effects of long-term treatments. The CATIE trial in the early 2000s showed that only 25% of people were on antipsychotics by the end of the trial; it is more important to engage patients than focus too much on medications' adverse effects.

Summarized and edited by Jorge Chalit, OMSII | Studio production by Jeffrey Olson, MS1

Episode 854: Tranq (xylazine) with Heroin Jun 05, 2023

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

What is Tranq?

Tranq is the street name for xylazine, a sedative drug typically used in veterinary medicine.
Xylazine has recently emerged as a recreational drug, often mixed with heroin or fentanyl.
The mechanism of action of xylazine is similar to dexmedetomidine (Precedex), an alpha-2 adrenergic receptor agonist.
At toxic levels, either by itself or when combined with opioids, can cause apnea, bradycardia, coma, and hypotension.

How is it different from other adulterants, such as fentanyl?

Because It is not an opioid, naloxone (Narcan) does not reverse its effects.
It may cause local peripheral vasoconstriction leading to necrotic ulcerations at sites of repeated injection.

How do you treat a suspected overdose of Tranq +/- an opioid?

Consult with a clinical toxicologist.
Naloxone should still be used despite its limited effect. At the very least it will not make the situation worse.
Be ready to intubate.
Provide supportive care.
Non-selective alpha antagonists are NOT recommended.

References

Ruiz-Colón K, Chavez-Arias C, Díaz-Alcalá JE, Martínez MA. Xylazine intoxication in humans and its importance as an emerging adulterant in abused drugs: A comprehensive review of the literature. Forensic Sci Int. 2014 Jul;240:1-8. doi: 10.1016/j.forsciint.2014.03.015. Epub 2014 Mar 26. PMID: 24769343.
Ayub S, Parnia S, Poddar K, Bachu AK, Sullivan A, Khan AM, Ahmed S, Jain L. Xylazine in the Opioid Epidemic: A Systematic Review of Case Reports and Clinical Implications. Cureus. 2023 Mar 29;15(3):e36864. doi: 10.7759/cureus.36864. PMID: 37009344; PMCID: PMC10063250.
Malayala SV, Papudesi BN, Bobb R, Wimbush A. Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Philadelphia, Pennsylvania, USA. Cureus. 2022 Aug 19;14(8):e28160. doi: 10.7759/cureus.28160. PMID: 36148197; PMCID: PMC9482722.
United States Drug Enforcement Administration. DEA Reports Widespread Threat of Fentanyl Mixed with Xylazine | DEA.gov. (n.d.). https://www.dea.gov/alert/dea-reports-widespread-threat-fentanyl-mixed-xylazine

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

Podcast 853: Critical Care Medications - Vasopressors May 29, 2023

Show notes

Contributor: Travis Barlock MD

Educational Pearls:

Three categories of pressors: inopressors, pure vasoconstrictors, and inodilators
Inopressors:

Epinephrine - nonselective beta- and alpha-adrenergic agonism, leading to increased cardiac contractility, chronotropy (increased heart rate), and peripheral vasoconstriction. Dose 0.1mcg/kg/min.
Levophed (norepinephrine) - more vasoconstriction peripherally than inotropy; useful in most cases of shock. Dose 0.1mcg/kg/min.

Peripheral vasoconstrictors:

Phenylephrine - pure alpha agonist; useful in atrial fibrillation because it avoids cardiac beta receptor activation and also in post-intubation hypotension to counteract the RSI medications. Start at 1mcg/kg/min and increase as needed.
Vasopressin - No effect on cardiac contractility. Fixed dose of 0.4 units/min.

Inodilators are useful in cardiogenic shock but often not started in the ED since patients mostly have undifferentiated shock

Dobutamine - start at 2.5mcg/kg/min.
Milrinone - 0.125mcg/kg/min.

References

1. Ellender TJ, Skinner JC. The Use of Vasopressors and Inotropes in the Emergency Medical Treatment of Shock. Emerg Med Clin North Am. 2008;26(3):759-786. doi:https://doi.org/10.1016/j.emc.2008.04.001

2. Hollenberg SM. Vasoactive drugs in circulatory shock. Am J Respir Crit Care Med. 2011;183(7):847-855. doi:10.1164/rccm.201006-0972CI

3. Lampard JG, Lang E. Vasopressors for hypotensive shock. Ann Emerg Med. 2013;61(3):351-352. doi:10.1016/j.annemergmed.2012.08.028

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

Podcast 852: Angioedema After Thrombolysis May 22, 2023

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

What is thrombolysis?

Thrombolysis is performed by administration of a medication that promotes the body's natural ability to break up clots. These medications include Alteplase (tPA) and Tenecteplase (TNK).
The main side effect of using such an agent is bleeding which typically occurs at puncture sites but can also occur internally. However, an unusual side effect of thrombolytic agents, which occurs in about 1-5% of cases, is angioedema.

What is angioedema?

Angioedema is a medical condition that causes swelling beneath the surface of the skin, typically in the face, lips, and throat (orolingual angioedema). Fluid leaks from blood vessels and accumulates in the deeper layers of the skin.

How are these two connected?

The mechanism by which angioedema occurs after thrombolysis is not well understood, but it is likely connected to how tPA can increase levels of bradykinin and histamine.
Swelling can appear suddenly but can also occur up to 24 hours after thrombolysis, and may last for a few hours or several days.
In some cases, angioedema can affect the airways, leading to difficulty breathing.

What can be done?

If this side effect occurs the provider can stop the medication or infusion and treat the patient with anti-histamines, steroids, epinephrine, and airway monitoring.
Medications such as Berinert or Icatibant, typically used in hereditary angioedema or ACE-i-induced angioedema, can also be used but have limited evidence for their efficacy.

Fun fact

tPA-related angioedema is about 4 times more likely in patients on ACE inhibitors. This is likely related to how ACE inhibitors also increase bradykinin and histamine in a patient's body.

References

Zhu A, Rajendram P, Tseng E, Coutts SB, Yu AYX. Alteplase or tenecteplase for thrombolysis in ischemic stroke: An illustrated review. Res Pract Thromb Haemost. 2022 Sep 20;6(6):e12795. doi: 10.1002/rth2.12795. PMID: 36186106; PMCID: PMC9487449.
Pahs L, Droege C, Kneale H, Pancioli A. A Novel Approach to the Treatment of Orolingual Angioedema After Tissue Plasminogen Activator Administration. Ann Emerg Med. 2016 Sep;68(3):345-8. doi: 10.1016/j.annemergmed.2016.02.019. Epub 2016 May 10. PMID: 27174372.
Burd M, McPheeters C, Scherrer LA. Orolingual Angioedema After Tissue Plasminogen Activator Administration in Patients Taking Angiotensin-Converting Enzyme Inhibitors. Adv Emerg Nurs J. 2019 Jul/Sep;41(3):204-214. doi: 10.1097/TME.0000000000000250. PMID: 31356244.
Sczepanski M, Bozyk P. Institutional Incidence of Severe tPA-Induced Angioedema in Ischemic Cerebral Vascular Accidents. Crit Care Res Pract. 2018 Sep 27;2018:9360918. doi: 10.1155/2018/9360918. PMID: 30363665; PMCID: PMC6180929.

Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS1

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