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 823: Immediate Resuscitative Thoracotomy Oct 24, 2022

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Immediate resuscitative thoracotomy can be performed in the ED to gain rapid access to the thoracic cavity in cases of traumatic cardiac arrest
Western Trauma Association Society Criteria for ED thoracotomy
- Blunt trauma +
- Penetrating trauma to torso +
- Penetrating trauma to the neck/extremity +
- Signs of life with refractory shock can consider resuscitative thoracotomy
Outcomes in immediate resuscitative thoracotomy are poor but are improving
A recent study evaluated over 2,000 patients meeting inclusion criteria for immediate resuscitative thoracotomy
- Overall survival rate of 20%
- - 26% survival rate in penetrating trauma
  - 7% survival rate in blunt trauma
- Predictors for poor outcomes
- - Patient age > 60 years
  - Blunt trauma mechanism of injury
  - A prehospital or ED HR
  - Absent signs of life at time of ED arrival
When criteria are met, immediate resuscitative thoracotomy should rapidly be performed in the ED

References

Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359-1363.

Panossian VS, Nederpelt CJ, El Hechi MW, et al. Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility. J Surg Res. 2020;255:486-494.

Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MS4 & 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/

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Podcast 822: Meralgia Paresthetica Oct 18, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Lateral Cutaneous Femoral Nerve Entrapment Syndrome, also known as Meralgia Paresthetica, results from entrapment of the lateral cutaneous femoral nerve, often as it exits the pelvis under the inguinal ligament.
Meralgia Paresthetica is associated with obesity, pregnancy, compression from clothing or belts and diabetes.
Symptoms include numbness, paresthesia and pain of the proximal lateral thigh. Signs or symptoms of radiculopathy such as weakness, loss of reflexes or severe back pain should not be present.
Diagnosis is clinical and does not require further imaging if there are no additional or concerning findings.
Meralgia Paresthetica typically resolves over time without intervention; however patients should be counseled on weight loss, diabetes control and avoidance of compressive clothing as relieving factors.

References

Solomons JNT, Sagir A, Yazdi C. Meralgia Paresthetica. Curr Pain Headache Rep. 2022;26(7):525-531. doi:10.1007/s11916-022-01053-7

Grossman MG, Ducey SA, Nadler SS, Levy AS. Meralgia paresthetica: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9(5):336-344. doi:10.5435/00124635-200109000-00007

Image from my.clevelandclinic.org

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

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Podcast 821: EKGs in Syncope Oct 17, 2022

Show notes

Contributor: Travis Barlock, MD

Educational Pearls:

An EKG should be obtained quickly after a syncopal event to identify possible life-threatening causes such as ischemia and arrhythmia
WOBBLER is a good mnemonic for remembering additional EKG findings to look for in syncope

Wolff-Parkinson-White (WPW)

Check for delta wave on QRS

Obstructed AV node

Any potential heart blocks

Brugada syndrome

Na channel blockade that can cause ST elevations in anterior leads

Bifascicular block

Conduction blockade in two of the three fascicles increases risk of complete heart block

Left Ventricular Hypertrophy (LVH)

Can be a sign of HOCM (younger patients) or aortic stenosis (older patients)

Epsilon waves

Positive deflections after the QRS that is seen in arrhythmogenic right ventricular dysplasia

Repolarization abnormalities

Prolonged/shortened QT segments

References

Martow E, Sandhu R. When Is Syncope Arrhythmic? Med Clin North Am. 2019;103(5):793-807.

Solbiati M, Dipaola F, Villa P, et al. Predictive Accuracy of Electrocardiographic Monitoring of Patients With Syncope in the Emergency Department: The SyMoNE Multicenter Study. Acad Emerg Med. 2020;27(1):15-23.

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

Podcast 820: Who Qualifies for Take-Home Naloxone Oct 11, 2022

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Home naloxone is traditionally given to those at high risk for opioid overdose such as those in the ED due to an opioid overdose, opioid intoxication, or admit to illicit opioid use
There are a number of other patient populations that benefit from home naloxone including those on chronic opioid or benzodiazepine therapy, and those who report any type of illicit drug use

Any illicit drug could be laced with opioids, and those who use drugs are more likely to be present as bystanders when an opioid overdose occurs

Some important tips to remember when prescribing home naloxone

There is often a scannable QR code that instructs bystanders on how to recognize and intervene in an overdose
Inform the patient that naloxone is temporary and those who overdose are at high risk of overdosing again
Provide support and inform the patient that if they decide they would like to enter treatment/rehabilitation programs, they can return to the ED to start that process

References

Strang J, McDonald R, Campbell G, et al. Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine. Drugs. 2019;79(13):1395-1418.

Moustaqim-Barrette A, Dhillon D, Ng J, et al. Take-home naloxone programs for suspected opioid overdose in community settings: a scoping umbrella review. BMC Public Health. 2021;21(1):597.

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

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Podcast 819: Indiscriminate Lactate Testing Oct 10, 2022

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Elevated lactate levels can be a useful indicator of critical illness in patients who meet SIRS criteria
Lactate can also be elevated due to other causes including seizures and medications such as albuterol and metformin
A recent study from Switzerland* performed routine point-of-care lactate testing in all elderly patients presenting at triage in the emergency department in order to determine the prevalence of elevated lactate in the population and its utility in predicting poor patient outcomes

Patients with seizure as their chief complaint were excluded from the study due to expected transient elevated lactate levels

Poor outcomes were defined as requiring extensive IVF and/orvasoactive medications, undergoing intubation, admission to the ICU, or death
27.1% of patients had an increased lactate but only 7.3% actually met poor outcome criteria
ED physicians should note that an increased lactate in an elderly patient does not mean that they are critically ill
Routine point-of-care lactate monitoring at triage is of limited usefulness and should instead be targeted towards those who meet critical illness criteria

*Errata: This study was performed in Switzerland, not Sweden as was stated in the podcast

References

Gosselin M, Mabire C, Pasquier M, et al. Prevalence and clinical significance of point of care elevated lactate at emergency admission in older patients: a prospective study. Intern Emerg Med. 2022;17(6):1803-1812.

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

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Podcast 818: Local Anesthetics and LAST Oct 04, 2022

Show notes

Contributor: Don Stader, MD

Educational Pearls:

There are two major groups of local anesthetics: Amide and Esther

To recall what group an anesthetic belongs to, use this memory trick:

Amide has an 'i' in the name and Amide anesthetics have 2 'i's e.g., Lidocaine. Ester has no 'i' and most common Ester anesthetics have only one 'i' e.g., Tetracaine.

In a true allergy and/or contraindication to both local anesthetic groups, diphenhydramine is an acceptable alternative.
Epinephrine is administered with local anesthetics to decrease bleeding, increase duration of action, and minimize systemic spread of the anesthetic, thus reducing toxicity.
Symptoms of Local Anesthetic Systemic Toxicity (LAST) may begin with dizziness, confusion and/or slurred speech, and can progress to cardiovascular collapse and death.
Treat LAST with lipid emulsion therapy i.e. 'Intralipids' to create a lipid sink that absorbs anesthetic agent

Administer initial 1.5 ml/kg bolus (approximately 100 ml in 70 mg adult) followed by infusion rate of 0.25 mg/kg/hour. Do not surpass 10 mg/kg total.

References

Dickerson DM, Apfelbaum JL. Local anesthetic systemic toxicity. Aesthet Surg J. 2014;34(7):1111-1119. doi:10.1177/1090820X14543102

Bina B, Hersh EV, Hilario M, Alvarez K, McLaughlin B. True Allergy to Amide Local Anesthetics: A Review and Case Presentation. Anesth Prog. 2018;65(2):119-123. doi:10.2344/anpr-65-03-06

Macfarlane AJR, Gitman M, Bornstein KJ, El-Boghdadly K, Weinberg G. Updates in our understanding of local anaesthetic systemic toxicity: a narrative review. Anaesthesia. 2021;76 Suppl 1:27-39. doi:10.1111/anae.15282

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

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Podcast 817: MI Risk during Elections Oct 03, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

2020 retrospective study with dat from two California hospitals compared rates of cardiovascular admissions in a five day period two weeks before and the five days after the presidential election
Hospitalization rate for acute cardiovascular disease increased by 17% and rate of acute myocardial infarction increased by 42%

Highest rates occurred in demographic of white males older than 75 years old

No significant difference between groups in rates of stroke and heart failure

References

Mefford MT, Rana JS, Reynolds K, et al. Association of the 2020 US Presidential Election With Hospitalizations for Acute Cardiovascular Conditions. JAMA Netw Open. 2022;5(4):e228031. Published 2022 Apr 1. doi:10.1001/jamanetworkopen.2022.8031

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

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Podcast 816: Ventilator Management in Asthmatics Sep 27, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

The management of severe asthma or COPD exacerbation is complex, especially when the patient requires intubation/ventilation
Asthma is an obstructive airway disease that can cause air trapping and hyperinflation of the lungs
To avoid worsening hyperinflation patients typically require slower respiratory rates, lower tidal volumes, and increased expiratory time when on a ventilator
- Patients on a ventilator require very close monitoring to prevent worsening hyperinflation and associated complications including barotrauma and hypotension/cardiac arrest secondary to decreased venous return
If patient condition starts to worsen, decrease respiratory rate and tidal volume
- In these cases, a decreased oxygen saturation is acceptable until their condition improves
If patient status continues to worsen, consider disconnecting the ventilator and pushing on the chest for approximately 30 seconds to help force out trapped air
If patient continues to decompensate, consider the possibility of a pneumothorax and determine if a chest tube is necessary
Remember to continue asthma/COPD management including albuterol/duonebs, steroids, magnesium, and alternatives including as heliox

References

Demoule A, Brochard L, Dres M, et al. How to ventilate obstructive and asthmatic patients. Intensive Care Med. 2020;46(12):2436-2449

Garner O, Ramey JS, Hanania NA. Management of Life-Threatening Asthma: Severe Asthma Series. Chest. 2022

Laher AE, Buchanan SK. Mechanically Ventilating the Severe Asthmatic. J Intensive Care Med. 2018;33(9):491-501

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

Podcast 815: Fluid Resuscitation in Pancreatitis Sep 26, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Historically, pancreatitis has been treated with aggressive IV fluid rehydration. Recently published data shows this may not be appropriate.
A randomized, controlled, multi-hospital trial evaluated outcomes for patients with acute pancreatitis receiving lactated Ringer's solution

Aggressive fluid resuscitation group received 20ml/kg bolus + 3ml/hour
Moderate fluid resuscitation groups received either 10 ml/kg bolus if hypovolemic or no bolus if normovolemic. Both moderate resuscitation groups received 1.5ml/hr.

The primary outcome was development of moderately severe or severe pancreatitis. 22.1% of aggressive fluid resuscitation and 17.3% of moderate fluid resuscitation patients developed primary outcome.
The safety outcome was fluid overload. Fluid overload developed in 20.5% of aggressive resuscitation group and only 6.3% of moderate resuscitation group.
This trial was ended early due to differences in safety outcomes without obvious difference in primary outcome
Overall, aggressive fluid resuscitation had no benefit in treatment of acute pancreatitis and providers should be aware of fluid overload risk.

References

de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022;387(11):989-1000. doi:10.1056/NEJMoa2202884

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

Podcast 814: Post-concussion Treatment Sep 19, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Recent study looked at the impact of screen time on duration of post-concussive symptoms
125 patients aged 12-25 diagnosed with a concussion were randomized to either abstain from or have unrestricted screen time for 48 hours after injury
Patients with unrestricted screen time averaged approximately 5 hours/day of screen time
Patients in the no screen time group averaged approximately 1 hour/day of screen time
Statistically significant difference in duration of post-concussive symptoms
- Unrestricted screen time cohort averaged 8 days of post-concussive symptoms
- No screen time cohort averaged 3.5 days of post-concussive symptoms
ED physicians should encourage patients to limit screen time as much as possible in the first 48 hours after a concussion to promote faster recovery from post-concussive symptoms

References

Macnow T, Curran T, Tolliday C, et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2021;175(11):1124-1131.

Summarized by Mark O'Brien, 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.

Donate to EMM today!

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