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 803: Sedation During Intubation Aug 08, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Awareness with recall of paralysis can occur in intubated and ventilated patients receiving paralytic medications

Patients who suffer from this effect are at high risk of developing severe PTSD, depression, and suicidal ideations
Occurs in approximately 0.1-0.2% of patients undergoing general anesthesia in an OR setting

2021 study showed patients intubated in the ED have a much higher rate of experiencing awareness during intubation

2.6% chance of awareness in patients undergoing intubation and mechanical ventilation in the ED
Higher rates with rocuronium likely due to its longer duration of action

New follow up study from 2022 showed 3.4% of patients aware when paralyzed for mechanical ventilation in ED

5.5% of patients receiving rocuronium had awareness occur
Patients who received other paralytics had a

Important to be proactive with sedation and pain medications to decrease risk of awareness with recall of paralysis, especially in patients receiving rocuronium

References

Fuller BM, Pappal RD, Mohr NM, et al. Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study. Crit Care Med. 2022.

Leslie K, Davidson AJ. Awareness during anesthesia: a problem without solutions? Minerva Anestesiol. 2010;76(8):624-628.

Pappal RD, Roberts BW, Mohr NM, et al. The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med. 2021;77(5):532-544.

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.

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Pediatric Palliative Care Expert Panel Aug 03, 2022

Show notes

Selected audio from our event, Palliative, hosted on June 27, 2022 in conjunction with Children's Hospital Colorado's Department of Palliative Medicine and The Denver Hospice's Footprints Program.

Keynote address by Dr. Nadia Tremonti, pediatric palliative care physician at Children's Hospital of Michigan

Expert Panel composed of Dr. Kimberly Bennett, medical director for TDH's Footprints Program, Dora Mueller, clinical nurse coordinator for palliative care at Children's and Cassie Matz, LCSW bereavement coordinator at Children's.

The evening commenced following a screening of the 2019 award-winning documentary, Palliative, featuring Dr. Nadia Tremonti's work at Children's Hospital of Michigan. You can watch the documentary for free at Kanopy.com using your library card using the following link: https://www.kanopy.com/product/palliative

Podcast 802: Intranasal Medication Administration for Pediatric Patients Aug 02, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Intranasal medication administration is a convenient, quick, and relatively painless option for pediatric patients
Often used as an initial medication to help control pain in children prior to establishing an IV
Using an atomizer is preferred when administering intranasal medications
The syringe should be angled towards the ipsilateral eye or occiput rather than straight upwards
Do not administer more than 1 mL of fluid per nostril as volumes greater than 1 mL are not sufficiently absorbed
Intranasal medication doses differ from the traditional IV dosages and have a slower onset of action

References

Del Pizzo J, Callahan JM. Intranasal medications in pediatric emergency medicine. Pediatr Emerg Care. 2014;30(7):496-501; quiz 502-494.

Fantacci C, Fabrizio GC, Ferrara P, Franceschi F, Chiaretti A. Intranasal drug administration for procedural sedation in children admitted to pediatric Emergency Room. Eur Rev Med Pharmacol Sci. 2018;22(1):217-222.

Rech MA, Barbas B, Chaney W, Greenhalgh E, Turck C. When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications. Ann Emerg Med. 2017;70(2):203-211.

Schoolman-Anderson K, Lane RD, Schunk JE, Mecham N, Thomas R, Adelgais K. Pediatric emergency department triage-based pain guideline utilizing intranasal fentanyl: Effect of implementation. Am J Emerg Med. 2018;36(9):1603-1607.

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

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Mental Health Monthly #14: Substance-Induced Psychosis (Part II) Jul 27, 2022

Show notes

In this second episode of a two-part mini-series, we feature Dr. Nadia Haddad, a Colorado psychiatrist, and Dr. Ricky Dhaliwal, an emergency medicine physician, as they discuss the various treatment modalities for substance-induced psychosis. They explore pharmacologic treatments, inpatient and outpatient treatments, and ways that emergency providers can improve their care for psychiatric patients with comorbid medical conditions. Lastly, they consider the different causes for repeat visits from mentally ill patients.

Key Points:

Pharmacologic treatments for substance-induced psychosis are similar to those for other types of psychosis; these include medications like Zyprexa, Haldol, and, as a third-line treatment, IM Thorazine.
Droperidol is used more commonly in the emergency setting, compared with the psychiatric setting.
Given the risk for respiratory depression from Zyprexa combined with benzodiazepines, psychiatrists may choose to use Thorazine or Haldol/Ativan/Benadryl instead.
It is important to reassess patients after substances wear off to determine whether they meet criteria for admission to inpatient psychiatry, though psychiatric assessments are limited by geographic constraints.
The admitting psychiatry team will reassess the patient to differentiate substance-induced psychosis vs other psychoses; often this includes obtaining collateral.
Helpful notes from the ED include: medications administered or restraints placed (can help extrapolate a patient's level of agitation), vital signs, prior records.
Some people will be more open about suicidality while intoxicated and less open about it while sober so it is important to obtain additional information for corroboration.
On average, patients stay in the detox unit for 3-4 days, though some may stay longer for protracted substance-induced psychosis if they have a long-standing history of daily substance use.
It is important to discharge patients with quick follow-up and potential placement into the various mental health programs including partial hospitalization, residential, or outpatient programs.
Emergency rooms can improve by taking psychiatric patients seriously, especially when they are transferred to the hospital from a psychiatric facility for medical management.
Repeat visits stem partially from the ambivalence that accompanies substance use disorders, including patients' difficulty in giving up the substance due the purpose it may serve in their lives.
Many substance use disorder programs are siloed from the medical system, which pose a challenge to interdisciplinary communication.

Podcast 801: Push Dose Vasopressors Jul 26, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

There are two common options for push-dose vasopressor: phenylephrine and epinephrine. Both have been studied in the setting of the OR, but are lacking data in emergency room utilization.
A recent retrospective study at one hospital compared the two options for effectiveness and safety. The data showed phenylephrine raised systolic pressure an average 26 points while epinephrine raised the systolic pressure higher, an average of 33 points.
Additionally, the same study showed dosing errors were more common in epinephrine. The error rates were 13% and 2% when using premixed syringes of epinephrine and phenylephrine respectively. However, overall no increase in adverse outcomes were reported between the two drugs in this study.

References

Nam E, Fitter S, Moussavi K. Comparison of push-dose phenylephrine and epinephrine in the emergency department. Am J Emerg Med. 2022;52:43-49. doi:10.1016/j.ajem.2021.11.033

Weingart S. Push-dose pressors for immediate blood pressure control. Clin Exp Emerg Med. 2015;2(2):131-132. Published 2015 Jun 30. doi:10.15441/ceem.15.010

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

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Podcast 800: Mortality in Fevers Jul 25, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

A recent study evaluated the association between the degree of fever and mortality rate in patients presenting to a set of Emergency Departments in Israel
Febrile patients with a temperature > 38.0 C were recorded and these patients were compared against local death records to determine the all-cause 30-day mortality rate
8.1% of patients evaluated in the ED were determined to be febrile
30-day mortality for all febrile patients was around 12%
Patients with fever >40 C have a mortality rate approaching 24%
Patients febrile to >40 C had increased mortality, ICU admissions, and AKIs compared to those with lesser degrees of fever
Those with a body temperature of between 39.2-39.5 C had the lowest mortality rates which may indicate the protective role of fever and warrants further research

References

Marcusohn E, Gibory I, Miller A, Lipsky AM, Neuberger A, Epstein D. The association between the degree of fever as measured in the emergency department and clinical outcomes of hospitalized adult patients. Am J Emerg Med. 2022;52:92-98.

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

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Podcast 799: EKG Abnormalities in Renal Failure Jul 19, 2022

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

Patients in renal failure may have elevated serum potassium levels which can result in EKG changes.
EKG changes in the setting of hyperkalemia generally depend on the serum level. Mild elevation may cause peaked T waves. At higher serum levels there will be loss of P waves plus wide complex tachycardia. There can be progression to fatal arrhythmias.
Treatment of acute hyperkalemia involves multiple mechanisms. Calcium gluconate stabilizes the cardiac membrane (of note, its duration of action is 1 hour). Insulin with Glucose and Bicarbonate both act to shift extracellular potassium into cells. Enhanced elimination of potassium is accomplished via Kayexalate or Lokelma. Definitive treatment for hyperkalemia is hemodialysis.
The differential for wide complex non-tachycardic rhythm on EKG includes: left ventricular hypertrophy, left bundle branch block, pacemaker, electrolyte abnormalities including hyperkalemia.

References

Palmer BF, Clegg DJ. Diagnosis and treatment of hyperkalemia. Cleve Clin J Med. 2017;84(12):934-942. doi:10.3949/ccjm.84a.17056

Watanabe R. Hyperkalemia in chronic kidney disease. Rev Assoc Med Bras (1992). 2020;66Suppl 1(Suppl 1):s31-s36. Published 2020 Jan 13. doi:10.1590/1806-9282.66.S1.31

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

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Podcast 798: Digit Reimplantation Jul 18, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Multiple factors affect if a digit can be reattached including: location of digit injury, mechanism of injury, duration since injury, preservation mechanism.
Recommended preservation is via indirect cooling. This is accomplished by wrapping the amputated digit piece in saline soaked gauze, placing the wrapped piece in a waterproof bag and putting the bag in ice water for transport. Avoid direct contact of the digit with ice.
A single center study showed that only 34% of the total digits received were properly preserved. Lower rates of indirect cooling were seen in patients arriving from home or via EMS (25% and 35% respectively). Of those transported from referring hospitals, still only 45% of digits were properly preserved. Therefore, consider providing preservation instructions for indirect cooling to those transporting amputated digits.

References

Zhang L, Azmat CE, Buckley CJ. Digit Amputation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; April 30, 2022.

Massand S, Sinatro H, Liu AT, Shen C, Ingraham JM. Improper Preservation of Amputated Parts: A Pervasive Problem. Plast Reconstr Surg Glob Open. 2020;8(9 Suppl):100-101. Published 2020 Oct 9. doi:10.1097/01.GOX.0000720828.15941.c5

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

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Podcast 797: Vitamin C in Sepsis Jul 12, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Prior, smaller studies showed intravenous Vitamin C given to patients with sepsis significantly improved patient mortality and additional outcomes.
A recently published, randomized control trial with >800 ICU patients who received up to 4 days of IV Vit C or placebo concluded that the end points of death or persistent organ dysfunction at 28 days were unaffected by Vitamin C administration. There were no adverse safety outcomes associated with Vitamin C administration.
Based on this trial, it is unlikely that Vitamin C will become a mainstay of treatment for sepsis patients.

References

Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229-1238. doi:10.1016/j.chest.2016.11.036

Lamontagne F, Masse MH, Menard J, et al. Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit. N Engl J Med. 2022;386(25):2387-2398. doi:10.1056/NEJMoa2200644

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

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Podcast 796: Fluid Amounts in Septic Shock Jul 11, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Septic shock management has traditionally endorsed rapid fluid resuscitation and the administration of vasopressors
Current guidelines are for patients to initially receive a 30 ml/kg fluid bolus then additional fluid as needed for continued hypotension
The ideal volume of fluid needed to maximize patient outcomes has been debated
A recent ICU-based study examined mortality differences between patient receiving restricted vs standard fluid therapy for septic shock
There was no significant difference in the rate of mortality or adverse outcomes between the two groups indicating that the amount of fluid used after the initial bolus does not affect patient outcomes
More research needed to evaluate the ideal fluid volumes used in the initial resuscitation of septic shock

Errata: *** "The primary outcome was death within 90 days after randomization"

References

Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247.

Meyhoff TS, Møller MH, Hjortrup PB, Cronhjort M, Perner A, Wetterslev J. Lower vs higher fluid volumes during initial management of sepsis: a systematic review with meta-analysis and trial sequential analysis. Chest. 2020;157(6):1478-1496.

Meyhoff TS, Hjortrup PB, Wetterslev J, et al. Restriction of Intravenous Fluid in ICU Patients with Septic Shock. N Engl J Med. 2022;386(26):2459-2470.

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

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