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 787: TAVR and Stroke Jun 06, 2022

Show notes

Contributor: Nick Hatch, MD

Educational Pearls:

Transcatheter aortic valve replacement (TAVR) is an increasingly common endovascular procedure to treat aortic stenosis
TAVR is an alternative to the open approach surgical aortic valve replacement (SAVR) for patients who are inoperable or are high risk surgical candidates
Following TAVR, there is increased risk of stroke, particularly in the first 30 days
TAVR-related strokes are due to embolic debris left on the valve root, which is generally cleaned out during SAVR
Further, following the procedure many patients are anticoagulated which increases the risk for conversion to hemorrhagic stroke
Isolated, unexplained nausea and vomiting in elderly patients should prompt concern for a neurologic workup with imaging - even more so if they have recently undergone TAVR

References

Davlouros PA, Mplani VC, Koniari I, Tsigkas G, Hahalis G. Transcatheter aortic valve replacement and stroke: a comprehensive review. J Geriatr Cardiol. 2018;15(1):95-104. doi:10.11909/j.issn.1671-5411.2018.01.008

Gleason TG, Reardon MJ, Popma JJ, et al. 5-Year Outcomes of Self-Expanding Transcatheter Versus Surgical Aortic Valve Replacement in High-Risk Patients. J Am Coll Cardiol. 2018;72(22):2687-2696. doi:10.1016/j.jacc.2018.08.2146

Siontis GCM, Overtchouk P, Cahill TJ, et al. Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of symptomatic severe aortic stenosis: an updated meta-analysis. Eur Heart J. 2019;40(38):3143-3153. doi:10.1093/eurheartj/ehz275

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & 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 786: Smiling Death May 31, 2022

Show notes

Contributor: Nick Hatch, MD

Educational Pearls:

"Smiling Death" describes the prehospital phenomenon of a person who is happy to be extricated from an extended period of crush injury, but dies suddenly soon after the rescue.
Smiling Death is caused by Crush Syndrome. Crush Syndrome begins when large areas of tissue are damaged by compression and subsequent impeded blood flow. Resultant cell death is followed by release of myoglobin and efflux of electrolytes including potassium. Upon removal of the crushing force, high levels of potassium enter circulation and cause cardiac arrhythmias leading to sudden death.
Prevention measures include aggressive hydration using normal saline before extrication. An acceptable starting rate is 1L per hour, but providers should take patient status into consideration and titrate appropriately.
Standard techniques for controlling hyperkalemia by intracellular shifting may be less effective. Early dialysis may be useful.

References

Gonzalez D. Crush syndrome. Crit Care Med. 2005;33(1 Suppl):S34-S41. doi:10.1097/01.ccm.0000151065.13564.6f

Better OS. Rescue and salvage of casualties suffering from the crush syndrome after mass disasters. Mil Med. 1999;164(5):366-369.

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

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Podcast 785: Pepper Spray May 30, 2022

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Pepper spray is a chemical irritant derived from oleoresin capsicum (OC), an extract from pepper plants. It can be used by police for riot or crowd control, or by individuals for self defense.
In the event of an exposure, those affected should immediately disperse from the area, remove contact lenses with clean or gloved hands, and remove contaminated clothing.
Pepper spray can spread from patients to providers by contact. When caring for those exposed, providers should use PPE including gloves and should double bag personal belongings.
For patient management consider the following:

If the eyes are affected, first remove contacts then irrigate with clean water. Use proparacaine drops for relief.
Clean exposed skin thoroughly with soap and water.
Inhalation and ingestion may cause nausea, vomiting, shortness of breath and generalized anxiety from discomfort. Treatment can include antiemetics and anxiolytics. Symptoms may persist for many days.

References

Schep LJ, Slaughter RJ, McBride DI. Riot control agents: the tear gases CN, CS and OC-a medical review. J R Army Med Corps. 2015;161(2):94-99. doi:10.1136/jramc-2013-000165

Tidwell RD, Wills BK. Tear Gas and Pepper Spray Toxicity. [Updated 2022 Jan 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544263/

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

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Podcast 784: Wastewater Surveillance for COVID May 24, 2022

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

About 50% of those infected with SARS-CoV-2 will shed the virus in their feces
Wastewater surveillance can be used to track COVID burden, which may be easier than collating test data from multiple hospitals across a region
Viral shedding begins 5-7 days prior to symptom onset, so wastewater data can be used to anticipate outbreaks and inform policy and public health initiatives
Some existing limitations to wastewater surveillance include:
Reporting by counties were water sources may be mixed
Septic tanks and other closed water systems will not be counted
Not all those infected will shed the virus

References

Weidhaas J, Aanderud ZT, Roper DK, et al. Correlation of SARS-CoV-2 RNA in wastewater with COVID-19 disease burden in sewersheds. Sci Total Environ. 2021;775:145790. doi:10.1016/j.scitotenv.2021.145790

Kirby AE, Walters MS, Jennings WC, et al. Using Wastewater Surveillance Data to Support the COVID-19 Response — United States, 2020–2021. MMWR Morb Mortal Wkly Rep 2021;70:1242–1244. DOI: http://dx.doi.org/10.15585/mmwr.mm7036a2

Covid-19 monitoring in wastewater. Colorado COVID-19 Updates. https://covid19.colorado.gov/covid-19-monitoring-in-wastewater. Accessed May 21, 2022.

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

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Podcast 783: LAD Occlusion & Troponin May 23, 2022

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

A study randomized 34 healthy patient to have their left anterior descending artery (LAD) occluded by balloon for 0, 15, 30, or 90 seconds
Subsequently, cardiac troponins (cTns) and Copeptin were measured every 15 minutes for 3 hours, then every 30 minutes for the next 3 hours
5 conclusions were drawn:

Copeptin is not a useful marker of cardiac ischemia
cTn may be detected after only 30 seconds of ischemia
cTn may be detected in a little as 15 minutes after ischemic event
After only 90 seconds of ischemia, cTn levels met threshold for MI
Troponin I is a better marker than troponin T as it rises faster and reaches a higher peak

Patients very recent or very brief ischemic events may have elevated troponin in the ED

References

Árnadóttir Á, Pedersen S, Bo Hasselbalch R, et al. Temporal Release of High-Sensitivity Cardiac Troponin T and I and Copeptin After Brief Induced Coronary Artery Balloon Occlusion in Humans [published correction appears in Circulation. 2021 Jun 22;143(25):e1116]. Circulation. 2021;143(11):1095-1104. doi:10.1161/CIRCULATIONAHA.120.046574

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

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Podcast 782: Ventilator Management May 17, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Tidal volume is the amount of breath a patient receives in a single ventilation
Traditional tidal volume (TV) setting was 10 ml/kg but studies showed lower TV had less incidence of respiratory distress, ARDS, and overall better outcomes
ED ventilation settings may get carried on for hours or days when a patient is admitted, making this an important part of patient care
Recent large systematic review shows that low TV setting in the ED leads to decreased incidence of ARDS, shorter ICU and hospital length of stay, shorter duration of mechanical ventilation, and decreased mortality
Consider an ED low tidal volume ventilation setting at around 6 ml/kg of predicted body weight

References

De Monnin K, Terian E, Yaegar LH, et al. Low Tidal Volume Ventilation for Emergency Department Patients: A Systematic Review and Meta-Analysis on Practice Patterns and Clinical Impact [published online ahead of print, 2022 Feb 7]. Crit Care Med. 2022;10.1097/CCM.0000000000005459. doi:10.1097/CCM.0000000000005459

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

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Podcast 781: Foxglove, Dropsy, and Salvador Dali May 16, 2022

Show notes

Contributor: Chris Holmes, MD

Educational Pearls:

Foxglove plant contains the cardiac glycoside digoxin
Foxglove leaf potions were once used to treat Dropsy; a historic term for symptoms of heart failure
Digoxin, previously used for treating heart failure, works by increases heart contraction strength and slows heart rate
Of note, the EKG of patient on digitalis may have a 'Dali Mustache' appearance
Digoxin toxicity can lead to a variety of dysrhythmias as well as neurological, GI, and metabolic effects
Treatment of digoxin toxicity is digoxin-immune fab, which is an antibody that binds digoxin

References

David MNV, Shetty M. Digoxin. [Updated 2021 Dec 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556025/

Cummings ED, Swoboda HD. Digoxin Toxicity. [Updated 2021 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470568/?report=classic

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

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Podcast 780: Pediatric Sedation Post-Intubation May 10, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Recent study looking at a pediatric emergency department to determine what percentage of patients after intubation received sedation within 10 minutes after intubation
About 25% of the patients in the study received sedation within 10 minutes after intubation
Only 75% of the patients in the study received sedation in the ED at some point after intubation
Those who received rocuronium were less likely to received sedation post-intubation

References

Berg K, Gregg V, Cosgrove P, Wilkinson M. The Administration of Postintubation Sedation in the Pediatric Emergency Department. Pediatr Emerg Care. 2021;37(11):e732-e735. doi:10.1097/PEC.0000000000001744

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Podcast 779: Pulse Pressure in Trauma May 09, 2022

Show notes

Contributor: Aaron Lessen, MD Educational Pearls:

Pulse pressure is the difference between the systolic and diastolic blood pressure, normal is about 40
A narrow pulse pressure is generally thought of as less than 30 mmHg which may signal peripheral vasoconstriction in response to lower blood volumes
2020 study examined hypotension and narrow pulse pressure in trauma and outcomes
37% of patients who were hypotensive on ED arrival had a severe injury, 22% of patients who had a narrow pulse pressure had a severe injury, and 11% of patients with normal blood pressure and normal pulse pressure had a severe injury
Need for thoracotomy, death, cardiac arrest, and need for other interventions was highest in the hypotensive group, the lowest in the normal blood pressure/normal pulse pressure group, and narrow pulse pressure group outcomes fell in the middle
Narrow pulse pressure in the setting of trauma may be a helpful vital sign to incorporate into trauma care in the ED

References

Schellenberg M, Owattanapanich N, Getrajdman J, Matsushima K, Inaba K. Prehospital Narrow Pulse Pressure Predicts Need for Resuscitative Thoracotomy and Emergent Intervention After Trauma [published correction appears in J Surg Res. 2021 Oct 6;270:1]. J Surg Res. 2021;268:284-290. doi:10.1016/j.jss.2021.06.051

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Podcast 778: tPA for Frostbite Injury May 03, 2022

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

Mild frostbite injury usually only requires supportive care
In severe frostbite injury, patients should receive an immediate angiogram, be admitted, and receive tPA if there is evidence of vascular occlusion
Salvage rate is around 80% for appropriate patients who receive tPA in phalangeal frostbite injury

References

Paine RE, Turner EN, Kloda D, Falank C, Chung B, Carter DW. Protocoled thrombolytic therapy for frostbite improves phalangeal salvage rates. Burns Trauma. 2020;8:tkaa008. Published 2020 Apr 10. doi:10.1093/burnst/tkaa008

Basit H, Wallen TJ, Dudley C. Frostbite. In: StatPearls. Treasure Island (FL): StatPearls Publishing; November 5, 2021.

Wexler A, Zavala S. The Use of Thrombolytic Therapy in the Treatment of Frostbite Injury. J Burn Care Res. 2017;38(5):e877-e881. doi:10.1097/BCR.0000000000000512

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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