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 842: "History of Wound Care" Jan 04, 2023

Show notes

Contributor: Chris Holmes, MD

Educational Pearls:

Through world history, there have been various interesting approaches to wound care
Ancient Egyptians applied honey, lint, and grease which provided antimicrobial, absorptive and moisturizing properties, respectively
Ancient Greeks irrigated wounds with clean water and applied wine and vinegar which may have been antimicrobial
One of the first synthetic topical antimicrobials was a dye researched by scientist Gerhard Domagk and later produced by Bayer under the name Prontosil
Some current wound care methods include wet-to-dry dressings, Dankin's Solution (sodium hypochlorite) and the use of maggots

References

Fleck CA. Why "wet to dry"?. J Am Col Certif Wound Spec. 2009;1(4):109-113. Published 2009 Oct 6. doi:10.1016/j.jcws.2009.09.003

Shah JB. The history of wound care. J Am Col Certif Wound Spec. 2011;3(3):65-66. doi:10.1016/j.jcws.2012.04.002

Ueno CM, Mullens CL, Luh JH, Wooden WA. Historical review of Dakin's solution applications. J Plast Reconstr Aesthet Surg. 2018;71(9):e49-e55. doi:10.1016/j.bjps.2018.05.023

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.

Podcast 841: Wound Care Jan 03, 2023

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Wound care in the emergency department aims to prevent future infection
Copious wound irrigation is the important step in preventing wound infection

Studies have shown that irrigation with tap water is just as effective, if not superior, to irrigation with saline or other solutions

Several studies have shown no reduction in wound infection rates when using sterile gloves during wound care

Recent study in the Netherlands compared infection rates between patients undergoing wound repair with and without sterile gloves
Receiving wound care with nonsterile gloves was noninferior to wound care utilizing sterile gloves

References

Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. Feb 15 2012;(2):Cd003861. doi:10.1002/14651858.CD003861.pub3

Heckmann N, Simcox T, Kelley D, Marecek GS. Wound Irrigation for Open Fractures. JBJS Rev. Jan 2020;8(1):e0061. doi:10.2106/jbjs.Rvw.19.00061

Zwaans JJM, Raven W, Rosendaal AV, et al. Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre randomised controlled trial. Emerg Med J. Sep 2022;39(9):650-654. doi:10.1136/emermed-2021-211540

Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

Podcast 840: Abnormal Pediatric Vitals at Discharge Dec 29, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Pediatric patients frequently have vital signs considered abnormal for age at discharge
Large multicenter study recently evaluated if pediatric patients discharged with abnormal vital signs have worse outcomes

97,824 pediatric discharges were included in the study
18.1% were discharged with vitals considered abnormal for age
No significant difference in readmission rates at 48 hours (2.28% in abnormal cohort vs. 2.45% in normal cohort)
No significant adverse outcomes in those discharged with abnormal vital signs (4 total PICU admissions with no deaths, CPR, or intubations)

When considering discharging pediatric patients, it is important to evaluate how the patient looks rather than just relying on vital signs

Consider leaving the child attached to a monitor, leaving the room, and then reevaluating them if they could be agitated by the presence of healthcare providers

References

Kazmierczak M, Thompson AD, DePiero AD, Selbst SM. Outcomes of patients discharged from the pediatric emergency department with abnormal vital signs. Am J Emerg Med. Jul 2022;57:76-80. doi:10.1016/j.ajem.202

Image from:

Vital Signs. MedlinePlus. https://medlineplus.gov/vitalsigns.html. Accessed December 29, 2022.

Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

Podcast 839: Causes of Pancreatitis Dec 19, 2022

Show notes

Contributor: Travis Barlock, MD

Educational Pearls:

The causes of pancreatitis can be remembered with the mnemonic: "GET SMASHED"

G: Gallstones (Most common cause of pancreatitis overall)
E: Ethanol (Alcohol consumption is the most common cause of chronic pancreatitis)
T: Trauma
S: Steroids
M: Malignancy
A: Autoimmune
S: Scorpion Sting
H: Hypertryglyceridemia
E: ERCP
D: Drugs (e.g. Valproate, Antiretrovirals)

References

Beyer G, Habtezion A, Werner J, Lerch MM, Mayerle J. Chronic pancreatitis. Lancet. 2020;396(10249):499-512. doi:10.1016/S0140-6736(20)31318-0

Lankisch PG, Apte M, Banks PA. Acute pancreatitis [published correction appears in Lancet. 2015 Nov 21;386(10008):2058]. Lancet. 2015;386(9988):85-96. doi:10.1016/S0140-6736(14)60649-8

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/

Donate to EMM today!

Podcast 838: Sternoclavicular Septic Arthritis Dec 13, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Septic arthritis of the sternoclavicular joint is uncommon accounting for
Immunosuppression and IV drug use increases the risk

Can account for up to 17% of septic arthritis cases in patients who use IV drugs

Symptoms are typically vague with pain presenting around where the sternum meets the clavicle
Consider imaging with CT or MRI and draining/analyzing the fluid if possible
Antibiotics are the mainstay of treatment, but surgery may be required to wash out joint and resect infected bone
As septic arteritis of the sternoclavicular join is uncommon, remember that patients presenting multiple times for the same complaint require a broader differential and a more extensive workup so that less common conditions are not missed

References

Gonçalves RB, Grenho A, Correia J, Reis JE. Sternoclavicular joint septic arthritis in a healthy adult: a rare diagnosis with frequent complications. J Bone Jt Infect. 2021;6(9):389-392. doi:10.5194/jbji-6-389-2021

Thompson MA, Barlotta KS. Septic Arthritis of the Sternoclavicular Joint. J Emerg Med. Jul 2018;55(1):128-129. doi:10.1016/j.jemermed.2018.02.044

Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Podcast 837: Snakebites Dec 12, 2022

Show notes

Contributor: Meghan Hurley, MD

Educational Pearls:

Venomous snakes in the United States include species from the family Elapidae and subfamily Crotalinae
In prehospital setting, elevate the bitten extremity and transport to hospital immediately

Do not attempt interventions with the bite site

Monitor for progression of swelling past any joint line, systemic symptoms or lab abnormalities for 8-12 hours

Symptoms may present up to hours after bite
Crotalinae venom has heme toxicity and may present with lab pattern of DIC

Treatment for all symptoms is antivenom

If symptoms persist or progress, continue to treat with antivenom

Compartment syndrome is rare with snake bites

References

Ruha AM, Kleinschmidt KC, Greene S, et al. The Epidemiology, Clinical Course, and Management of Snakebites in the North American Snakebite Registry. J Med Toxicol. 2017;13(4):309-320. doi:10.1007/s13181-017-0633-5

Aziz H, Rhee P, Pandit V, Tang A, Gries L, Joseph B. The current concepts in management of animal (dog, cat, snake, scorpion) and human bite wounds. J Trauma Acute Care Surg. 2015;78(3):641-648. doi:10.1097/TA.0000000000000531

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Podcast 836: Humming to get EJ Dec 06, 2022

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Two conventional ways to aid in external jugular vein (EJ) catheter placement are Trendelenburg's position and Valsalva's maneuver by patient
One study compared ultrasound visualization of cross sections of EJ and common femoral vein at baseline and with patients in Trendelenburg's position, Valsalva's maneuver, and while humming
The study found all three conditions distended the veins from baseline, but there was no significant difference in diameter between the conditions
Humming may be a viable technique in distended EJ for catheter placement, and may be easier for patients to comprehend than Valsalva

References

Lewin MR, Stein J, Wang R, et al. Humming is as effective as Valsalva's maneuver and Trendelenburg's position for ultrasonographic visualization of the jugular venous system and common femoral veins. Ann Emerg Med. 2007;50(1):73-77. doi:10.1016/j.annemergmed.2007.01.024

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Podcast 835: Syncope Review Dec 05, 2022

Show notes

Contributor: Meghan Hurley, MD

Educational Pearls:

Syncope is defined as a loss of consciousness with an immediate return to baseline
Differential is broad

Cardiogenic

Structural (aortic stenosis, HOCUM, etc.)
Electrical (long QT syndrome, Brugada, etc.)

Neurogenic/neurovascular (brain bleed, etc.)
Seizure
Everything else

Hypoglycemia, anemia, and bleeding into the abdominal cavity are some potential causes to rule out

Vasovagal

Diagnosis of exclusion

Work Up

EKG
Good H&P
Labs especially Hb and glucose

References

Morris J. Emergency department management of syncope. Emerg Med Pract. Jun 2021;23(6):1-24.

Reed MJ. Approach to syncope in the emergency department. Emerg Med J. Feb 2019;36(2):108-116. doi:10.1136/emermed-2018-207767

Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Podcast 834: Peds Buckle Fractures Nov 29, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Torus (Buckle) fractures are a commonly encountered pediatric fracture pattern

Typically presents as wrist pain secondary to a child falling on outstretched hand
One edge of the bone "buckles" or bends because children's bones are softer and more pliable

Management

Older studies have shown that short term immobilization with a velcro splint and primary care follow up is sufficient
Recent randomized trial compared immobilization with Velcro splint with as needed wrist support using a gauze wrap
No significant differences noted in outcomes between the two cohorts

Physicians can consider using an ace or gauze wrap as needed for buckle fracture management along with OTC analgesics for pain management

References

Asokan A, Kheir N. Pediatric Torus Buckle Fracture. StatPearls. StatPearls Publishing

Kennedy SA, Slobogean GP, Mulpuri K. Does degree of immobilization influence refracture rate in the forearm buckle fracture? J Pediatr Orthop B. Jan 2010;19(1):77-81. doi:10.1097/BPB.0b013e32832f067a

Perry DC, Achten J, Knight R, et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet. Jul 2 2022;400(10345):39-47. doi:10.1016/s0140-6736(22)01015-7

Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Podcast 833: NS vs LR Nov 28, 2022

Show notes

Contributor: Travis Barlock, MD

Educational Pearls:

Normal Saline (NS) contains 154 mEq of both Sodium (Na) and Chloride (Cl), and has a pH of 5.5

Normal Na and Cl in adult humans are about 140 mEq/L and 103 mEq/L. respectively

Excess negative charge resulting from hyperchloremia is managed via bicarbonate excretion leading to loss of base

Overall, administration of NS drives metabolic acidosis

Lactated Ringers (LR) contains 130 mEq of Na and 109 mEq Cl, and has a pH of 6.5
LR components are closer to physiologic levels thus may generally be a more efficacious fluid choice
NS is still frequently given in scenarios where there is concern for increased intracranial pressure or existing hypochloremic alkalosis from emesis.

ReferencesLi H, Sun SR, Yap JQ, Chen JH, Qian Q. 0.9% saline is neither normal nor physiological. J Zhejiang Univ Sci B. 2016;17(3):181-187. doi:10.1631/jzus.B1500201

Lehr AR, Rached-d'Astous S, Barrowman N, et al. Balanced Versus Unbalanced Fluid in Critically Ill Children: Systematic Review and Meta-Analysis. Pediatr Crit Care Med. 2022;23(3):181-191. doi:10.1097/PCC.0000000000002890

Self WH, Semler MW, Wanderer JP, et al. Saline versus balanced crystalloids for intravenous fluid therapy in the emergency department: study protocol for a cluster-randomized, multiple-crossover trial. Trials. 2017;18(1):178. Published 2017 Apr 13. doi:10.1186/s13063-017-1923-6

Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829-839. doi:10.1056/NEJMoa1711584

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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