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 813: Pulse Oximetry Sep 13, 2022

Show notes

Contributor: Travis Barlock, MD

Educational Pearls:

Most oxygen in the body is bound to hemoglobin, forming oxyhemoglobin. Less than 1% of the oxygen in the body is dissolved in plasma.
Pulse Oximeters (Pulse Ox) function by emitting wavelengths of light from one side, and capturing the amount absorbed on the opposite side. A calculation determined the amount of saturation.
Pulse Ox relies on pulsations in arterial flow to create a photoplethysmogram (pleth) for measurements
- Patients with poor peripheral perfusion may have unreliable pulse ox.
- Patient with an LVAD have constant flow and also unreliable pulse ox.
Pulse Ox is a useful tool when pacing to determine mechanical capture. If there is disparity between the electrical wave pulse and the rate on pulse ox, there is likely no mechanical capture leading to poor distal flow.

References

Eecen CMW, Kooter AJJ. Pulsoximeters: werking, valkuilen en praktische tips [Pulse oximetry: principles, limitations and practical applications]. Ned Tijdschr Geneeskd. 2021;165:D5891. Published 2021 May 11.

Elgendi M. On the analysis of fingertip photoplethysmogram signals. Curr Cardiol Rev. 2012;8(1):14-25. doi:10.2174/157340312801215782

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.

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Podcast 812: PO Medications Sep 12, 2022

Show notes

Contributor: Nick Tsipis, MD

Educational Pearls:

PO medications are less frequently used in the ED due to their longer onset of action
The position the patient is in when given PO medications may affect how quickly the medication is absorbed

The quicker the medication passes through the stomach into the small intestine, the quicker it can be absorbed and metabolized

Recent study used in silico gastric biomechanics model to compare the length of time it took PO medications to pass through the stomach based on the patient's positioning

Compared the medication transit time in a stomach model placed in right lateral, left lateral, upright, and supine positions
Right lateral positioning resulted in the fastest time for medication to pass through the stomach and enter the duodenum

Likely due to the direction of gravity aligning with the antrum and pylorus of the stomach

Left lateral positioning had the slowest time for the pill to enter the small intestine

Likely due to gravity not aligning with stomach anatomy

The time to absorption in the right and left lateral position were significantly faster and slower respectively than that seen in the upright and supine positions

These results indicate that placing a patient in the right lateral position when giving PO medications may result in faster rate of medication onset than if the patient is in another position

References

Lee JH, Kuhar S, Seo JH, Pasricha PJ, Mittal R. Computational modeling of drug dissolution in the human stomach: Effects of posture and gastroparesis on drug bioavailability. Phys Fluids (1994). 2022;34(8):081904.

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

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Podcast 811: Ketamine for Pain Sep 07, 2022

Show notes

Contributor: Lessen, Aaron MD

Educational Pearls:

Ketamine can be given at 0.2-0.3 mg/kg as subdissociative doses for pain control in the ED
- Ketamine coadministered with Haldol may reduce agitation
A recent study in Iran compared subdissociative Ketamine given with 2.5 mg Haldol to 1 mg/kg Fentanyl for pain control in the ED
- Ketamine with Haldol had better pain control than Fentanyl at 5, 10, 15 and 30 minutes
- Ketamine with Haldol less frequently required rescue medication
- Ketamine with Haldol did have increased agitation at only the 10 minute mark
- Of note, there was not a Ketamine only group to compare
Ketamine with Haldol is a viable alternative combination for pain control

References

Moradi MM, Moradi MM, Safaie A, Baratloo A, Payandemehr P. Sub dissociative dose of ketamine with haloperidol versus fentanyl on pain reduction in patients with acute pain in the emergency department; a randomized clinical trial. Am J Emerg Med. 2022;54:165-171. doi:10.1016/j.ajem.2022.02.012

Sin B, Ternas T, Motov SM. The use of subdissociative-dose ketamine for acute pain in the emergency department. Acad Emerg Med. 2015;22(3):251-257. doi:10.1111/acem.12604

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

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Podcast 810: Tooth Replantation Sep 05, 2022

Show notes

Contributor: Jarod Scott, MD

Educational Pearls:

There is a 1-hour window for tooth replantation in ED
Cold milk is often best transport media unless there is access to specialized solutions (Hank's Balanced Solution)

Goal is to preserve periodontal ligament
Soaking in tap water should be avoided as it will lyse cells of periodontal ligament

If oral surgeon is rapidly available, have them perform replantation

Do not delay replantation to wait for an oral surgeon to become available

Steps in tooth reimplantation

Disturb the socket as little as possible
Handle tooth only by crown, don't touch root
Rinse tooth gently with tap water or saline, do not scrub it
Tooth should click back in place and remain stable
Don't manipulate after reimplantation

It may take weeks to determine if the tooth will survive
Studies have shown that replantation performed within one hour has a significantly better prognosis than those taking place after a greater amount of time has passed

References

Andreasen JO, Andreasen FM, Skeie A, Hjørting-Hansen E, Schwartz O. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article. Dent Traumatol. 2002;18(3):116-128.

De Brier N, O D, Borra V, Singletary EM, Zideman DA, De Buck E. Storage of an avulsed tooth prior to replantation: A systematic review and meta-analysis. Dent Traumatol. 2020;36(5):453-476.

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

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Podcast 809: Achilles Tendon Rupture Aug 30, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Achilles tendon rupture usually presents in younger, healthy patients after a sports injury
Patients typically present complaining of an abrupt onset ankle pain after feeling a "pop"
- Pain can be localized to posterior ankle and patient's lack the ability to plantarflex
- Achilles rupture is a clinical diagnosis and does not usually require imaging in the ED
- Thompson test
- - Having patient lay on their stomach and squeezing the calf on the injured side should result in plantarflexion
  - If the Achilles is ruptured, no plantarflexion will occur
Treatment in the ED is to place the patient in a short leg posterior splint with some mild plantarflexion to aid in healing
After discharge patients should follow up with orthopedics
Recent study compared those who underwent the traditional open surgery, a minimally invasive surgery, and no surgery
- No difference in functionality was noted between the groups 3 months to 1 year post injury
- Those in the nonoperative group had slightly higher rates of repeat rupture (6%) than those in the surgical groups (
- Patients undergoing minimally invasive surgery had the highest risk of nerve injury (5.2%), followed by traditional surgery (2.8%), and then nonoperative (0.6%)

References

Cuttica DJ, Hyer CF, Berlet GC. Intraoperative value of the thompson test. J Foot Ankle Surg. 2015;54(1):99-101.

Kauwe M. Acute Achilles Tendon Rupture: Clinical Evaluation, Conservative Management, and Early Active Rehabilitation. Clin Podiatr Med Surg. 2017;34(2):229-243.

Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or Surgical Treatment of Acute Achilles' Tendon Rupture. N Engl J Med. 2022;386(15):1409-1420.

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

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Podcast 808: BVM and PEEP Valve Aug 29, 2022

Show notes

Contributor: Dylan Luyten, MD

Educational Pearls:

Positive End Expiratory Pressure (PEEP) is positive pressure within the lungs and maintained throughout the entire respiratory cycle. It is the pressure preventing alveoli from collapsing at the end of exhalation.
When using a bag valve mask (BVM) to ventilate patients, always attach the PEEP valve to prevent intrathoracic pressure from returning to atmospheric pressure which would allow alveoli collapse.
A BVM with a good seal to patients face and with an attached PEEP valve provides the same support as BiPAP or CPAP.
A generally acceptable PEEP setting is 5 cmH2O.

References

Mora Carpio AL, Mora JI. Positive End-Expiratory Pressure. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 27, 2021.

Harrison MJ. PEEP and CPAP. Br Med J (Clin Res Ed). 1986;292(6521):643-644. doi:10.1136/bmj.292.6521.643

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

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Podcast 807: Ring Removal Tricks Aug 23, 2022

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

If a patient is in significant pain, a digital block can be helpful. Pain management alone may allow for manual ring removal.
Ring cutters and trauma shears with specialized ring cutters can be attempted but will destroy the ring and some materials may be resistant to cutting.
2 alternative options are presented which aim to reduce edema above the ring to assist removal:

Move the ring as proximally as possible. Wrap large size suture from the ring distally beyond PIP joint. Slide the ring over the suture and off the finger.
Wrap a tourniquet from distal to proximal including over the ring. Have the patient hold the tourniquet in place while they elevate their hand above the head for 15 minutes. Take down the tourniquet then remove the ring.

References

Asher CM, Fleet M, Bystrzonowski N. Ring removal: an illustrated summary of the literature. Eur J Emerg Med. 2020;27(4):268-273. doi:10.1097/MEJ.0000000000000658

Walter J, DeBoer M, Koops J, Hamel LL, Rupp PE, Westgard BC. Quick cuts: A comparative study of two tools for ring tourniquet removal. Am J Emerg Med. 2021;46:238-240. doi:10.1016/j.ajem.2020.07.039

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

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Podcast 806: Normal ECGs Aug 22, 2022

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Physicians are typically advised not to trust computer interpretation of ECGs
Retrospective study was done of computer interpreted normal ECGs to evaluate the accuracy of such an interpretation

989 ECGs were interpreted as "Normal sinus rhythm, Normal ECG" by proprietary cardiology software on MUSE Cardiology Information System
These EKGs received follow up interpretation by cardiologists which was considered the "gold standard" for interpretation
18.6% of "normal ECG" had at least one abnormality identified by the cardiologist

6.1% of these discrepant interpretations were deemed potentially clinically significant
Only 1% were classified as possible ischemia

On retrospective chart review:

Six patients underwent non-emergent cardiac catheterization
Two had cardiac interventions

One had three PCI stents to a prior CABG graft
One had a scheduled outpatient cardiac catheterization but was admitted and ended up receiving a CABG graft

Study showed that discrepancies between computer interpretation of "Normal ECG" and cardiologist re-interpretation were not clinically significant
Emergency physicians should still screen ECGs per AHA guidelines

References

Winters LJ, Dhillon RK, Pannu GK, Terrassa P, Holmes JF, Bing ML. Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. Am J Emerg Med. 2022;51:384-387.

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

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Podcast 805: Tunneled Peritoneal Catheter Aug 16, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Patients with recurrent ascites may need frequent outpatient or emergency department paracentesis which can be time consuming and uncomfortable for patients.
Tunneled peritoneal catheters are a permanent alternative therapy which allows fluid drainage at home by patient or caregiver.
There has been theoretical concern that long term placement of tunneled peritoneal catheters may increase risk of infection, thus they are more commonly placed as a palliative measure for patients with end stage cancer and malignant ascites with shorter anticipated life spans.
However, a recent small study found that in both patients with malignant ascites and recurrent ascites from cirrhosis, tunneled peritoneal catheter placement reduced symptoms from ascites and did not increase risk of infection or leakage at catheter site, or spontaneous bacterial peritonitis after four weeks. More research is emerging and tunneled peritoneal catheters may become more common.

References

Kimer N, Riedel AN, Hobolth L, et al. Tunneled Peritoneal Catheter for Refractory Ascites in Cirrhosis: A Randomized Case-Series. Medicina (Kaunas). 2020;56(11):565. Published 2020 Oct 27. doi:10.3390/medicina56110565Petzold G, Bremer SCB, Heuschert FC, et al. Tunnelled Peritoneal Catheter for Malignant Ascites-An Open-Label, Prospective, Observational Trial. Cancers (Basel). 2021;13(12):2926. Published 2021 Jun 11. doi:10.3390/cancers13122926Corrigan M, Thomas R, McDonagh J, et al. Tunnelled peritoneal drainage catheter placement for the palliative management of refractory ascites in patients with liver cirrhosis. Frontline Gastroenterol. 2020;12(2):108-112. Published 2020 Feb 28. doi:10.1136/flgastro-2019-101332

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

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Podcast 804: Brugada Criteria for V Tach Aug 09, 2022

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

Tachycardia describes a heart rate of >120 beats per minute
Wide Complex describes a QRS duration of >120 ms or 3 small boxes on a standard EKG
The major differential for a wide complex tachycardia is Ventricular Tachycardia (VT), aka "V Tach", or Supraventricular Tachycardia (SVT) with Aberrancy

SVT alone is a narrow complex tachycardia, but as rate increases a right or left bundle branch block pattern may emerge, creating SVT with Aberrancy seen as a wide complex on EKG
It is important to distinguish the rhythms as treatment for stable VT differs from treatment(s) for stable SVT

Brugada Criteria is an algorithm for determining if wide complex tachycardia is VT with a high degree of sensitivity and specificity.
Following is a simple ED approach based on brugada criteria to determine VT on EKG. If either condition is true, suspect and treat VT:

Concordance: All precordial leads have QRS complexes that are either all positive or all negative.
R-S interval: >100 ms in any one precordial lead.

Also note that VT is more common in patients who are elderly and/or have cardiac comorbidities of ischemic or structural heart disease

References

Reithmann C. Tachykardien mit breiten QRS-Komplexen [Differential diagnosis of wide QRS complex tachycardia]. MMW Fortschr Med. 2019;161(13):48-56. doi:10.1007/s15006-019-0022-x

Ding WY, Mahida S. Wide complex tachycardia: differentiating ventricular tachycardia from supraventricular tachycardia. Heart. 2021;107(24):1995-2003. doi:10.1136/heartjnl-2020-316874

Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83(5):1649-1659. doi:10.1161/01.cir.83.5.1649

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

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