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 769: Pressors After Cardiac Arrest Apr 04, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Hypotension after cardiac arrest often requires a vasopressor to improve blood pressure
Recent observational study from France examined outcomes of patients who received either epinephrine or norepinephrine for post-resuscitation shock
Norepinephrine had significantly better outcomes

Death from shock was 35% in the epinephrine group vs. 9% in the norepinephrine group
Recurrent cardiac arrest was 9% in epinephrine group vs. 3% in norepinephrine group

For epinephrine:

The all cause mortality was 2.5 times higher than norepinephrine
Cardiovascular mortality was 5 times higher than norepinephrine
Favorable neurological outcomes was 3 times worse than norepinephrine

References

Bougouin W, Slimani K, Renaudier M, Binois Y, Paul M, Dumas F, Lamhaut L, Loeb T, Ortuno S, Deye N, Voicu S, Beganton F, Jost D, Mekontso-Dessap A, Marijon E, Jouven X, Aissaoui N, Cariou A; Sudden Death Expertise Center Investigators. Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock. Intensive Care Med. 2022 Mar;48(3):300-310. doi: 10.1007/s00134-021-06608-7. Epub 2022 Feb 7. PMID: 35129643.

Summarized by John Spartz, MS4 | Edited by 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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Mental Health Monthly #11: De-escalation: Changing Confrontation to Collaboration Mar 30, 2022

Show notes

Contributor: Dr. Kimberly Nordstrom

De-escalation usually takes less time than physical and chemical restraints, which leads to decreased injury to staff members, better patient trust and increased patient throughput as accepting facilities oftentimes delay transfer acceptance following physical restraints
Prepare to engage prior to entering their room in two ways: cognitively and emotionally
- Why do you want to de-escalate the patient? Remind yourself you don't want to introduce more trauma
- Check your emotions, and ensure you don't bring your emotional state into
If possible, engage the patient when they're in mild agitation before their anger is out of control
Be authoritative not authoritarian or permissive, impart your expertise in medicine and explain your rationale to them without claiming to be an expert on them personally
Small acts of kindness like the provision of a warm blanket, snacks or voluntary medications appropriate to the situation can aid in establishing trust and rapport
Take a break to cool off if the interaction is too charged
Verbal de-escalation pearls:
- Respectful introduction, etiquette can be perceived as empathy to a patient in crisis
- Confirm story and allow patient to offer corrections to what you've been told
- Utilize active listening techniques, both verbally and nonverbally
- Avoid assigning blame, but use distant third parties if necessary without being detrimental to your colleagues
- Offer choices in medications within your clinical comfort zone for the patient

Verbal De-escalation videos:

Identification and Assessment of Agitation

Basic Elements of Verbal De-escalation

More Practice with Verbal De-escalation

Advanced Skills in De-escalation

Personal Safety and Escape Skills

References:

Berlin JS. Collaborative De-escalation. In: Zeller SL, Nordstrom KD, Wilson MP, eds. The Diagnosis and Management of Agitation. Cambridge: Cambridge University Press; 2017:144-155. doi:10.1017/9781316556702.012
Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25. doi:10.5811/westjem.2011.9.6864

Summarized by Mason Tuttle

Podcast 768: Takotsubo Cardiomyopathy Mar 29, 2022

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

3% of cases of acute coronary syndrome are due to Takotsubo
Takotsubo cardiomyopathy or "broken heart syndrome" can occur with severe physiologic or emotional stressors, as these events can result in a profound outpouring of sympathetic neurotransmitters (epinephrine/norepinephrine)
Receptors for these catecholamines are very dense around the apex of the heart, so the apical aspect of the heart can balloon outward as a result of this surge
Most often cases resolve in several weeks although in rare cases it can lead to congestive heart failure or a thrombus formation

References

Ahmad SA, Brito D, Khalid N, et al. Takotsubo Cardiomyopathy. [Updated 2022 Jan 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430798/

Bossone E, Savarese G, Ferrara F, et al. Takotsubo cardiomyopathy: overview. Heart Fail Clin. 2013;9(2):249-x. doi:10.1016/j.hfc.2012.12.015

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

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Podcast 767: Transaminitis and Rhabdomyolysis Mar 28, 2022

Show notes

Contributor: Sam Killian, MD

Educational Pearls:

Transaminitis refers to the elevation of transaminases, enzymes of the liver (AST and ALT)
Elevation of ALT is relatively specific to the liver, but AST is found in more organs than the liver including the muscle
If AST is significantly greater than ALT, consider a musculoskeletal origin such as rhabdomyolysis
Transaminitis is not always a liver specific issue

References

Lala V, Goyal A, Minter DA. Liver Function Tests. [Updated 2021 Aug 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482489/

Lim AK. Abnormal liver function tests associated with severe rhabdomyolysis. World J Gastroenterol. 2020;26(10):1020-1028. doi:10.3748/wjg.v26.i10.1020

Jo KM, Heo NY, Park SH, et al. Serum Aminotransferase Level in Rhabdomyolysis according to Concurrent Liver Disease. Korean J Gastroenterol. 2019;74(4):205-211. doi:10.4166/kjg.2019.74.4.205

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

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Podcast 766: Truth about Tramadol Mar 22, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Tramadol is often thought of as a mild-opiate to use for analgesia, but it is a more complicated drug
Tramadol needs to be metabolized into an effective drug making it not pharmacologically reliable

3-10% of people cannot metabolize tramadol and it does not work
Some others over-metabolize tramadol and it causes greater effect

Studies have shown it is not any better as a acetaminophen or ibuprofen for analgesia, it can lower a seizure threshold, and it acts to inhibit serotonin reuptake
Recent study evaluated all-cause mortality of tramadol compared to codeine and found tramadol had nearly double the all-cause mortality as those prescribed codeine
Overall tramadol has many risks and should be critically evaluated before prescribing

References

Dhesi M, Maldonado KA, Maani CV. Tramadol. [Updated 2021 May 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537060/

Association of tramadol vs codeine prescription dispensation with mortality and other adverse clinical outcomes Xie J, Strauss VY, Martinez-Laguna D, et al. JAMA. 2021;326(15):1504-1515.

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

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Podcast 765: Phenobarbital for Alcohol Withdrawal Mar 21, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Retrospective cohort study looked at return rate of discharged patients after receiving either phenobarbital or benzodiazepines or both in the ED for treatment of alcohol withdrawal
Patients who received benzodiazepines had a 25% chance of returning in 3 days versus a 10% chance of returning in 3 days for those who received phenobarbital
13% of patients returned in 3 days after receiving both phenobarbital and benzodiazepines
Phenobarbital may make it less likely for patients to come back to the ED after receiving treatment for alcohol withdrawal

References

Lebin JA, Mudan A, Murphy CE 4th, Wang RC, Smollin CG. Return Encounters in Emergency Department Patients Treated with Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal. J Med Toxicol. 2022;18(1):4-10. doi:10.1007/s13181-021-00863-2

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

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Podcast 764: Myth or Merit: Beta-Blockers for Cocaine Chest Pain Mar 15, 2022

Show notes

Contributor: Chris Holmes, MD

Educational Pearls:

Many are taught that patients with cocaine chest pain should not receive beta-blockers due to unopposed alpha agonism, but is this true?
363 consecutive admissions for chest pain with positive cocaine on urine toxicology were reviewed in a retrospective cohort study
60 patients in this cohort received a beta-blocker and multivariate analysis demonstrated a reduction in myocardial infarction risk
Another retrospective cohort study demonstrated no association of negative outcomes with beta-blocker administration in those with a recent positive result on cocaine urine toxicology
Two more recent meta-analyses were performed finding no association between adverse clinical outcomes and beta-blocker administration for cocaine chest pain
No prospective randomized-controlled trials have been performed to evaluate the use of beta-blockers for treatment of cocaine chest pain in the ED setting

References

Dattilo PB, Hailpern SM, Fearon K, Sohal D, Nordin C. Beta-blockers are associated with reduced risk of myocardial infarction after cocaine use [published correction appears in Ann Emerg Med. 2008 Jul;52(1):90]. Ann Emerg Med. 2008;51(2):117-125. doi:10.1016/j.annemergmed.2007.04.015

Rangel C, Shu RG, Lazar LD, Vittinghoff E, Hsue PY, Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010;170(10):874-879. doi:10.1001/archinternmed.2010.115

Pham D, Addison D, Kayani W, et al. Outcomes of beta blocker use in cocaine-associated chest pain: a meta-analysis. Emerg Med J. 2018;35(9):559-563. doi:10.1136/emermed-2017-207065

Lo KB, Virk HUH, Lakhter V, et al. Clinical Outcomes After Treatment of Cocaine-Induced Chest Pain with Beta-Blockers: A Systematic Review and Meta-Analysis. Am J Med. 2019;132(4):505-509. doi:10.1016/j.amjmed.2018.11.041

Richards JR, Hollander JE, Ramoska EA, et al. β-Blockers, Cocaine, and the Unopposed α-Stimulation Phenomenon. J Cardiovasc Pharmacol Ther. 2017;22(3):239-249. doi:10.1177/1074248416681644

Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990;112(12):897-903. doi:10.7326/0003-4819-112-12-897

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

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Podcast 763: Sternoclavicular Infection Mar 14, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Septic arthritis can occur at any joint, including the sternoclavicular joint
Sternoclavicular joint infections comprise 1% of all bone and joint infections
Patients who use intravenous drugs have a higher occurrence of this type of infection compared to the general population, accounting for 17% of all sternoclavicular joint infections
Usual treatment includes intravenous antibiotics and, in some cases, surgery

References

Tapscott DC, Benham MD. Sternoclavicular Joint Infection. [Updated 2021 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551721/

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

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UnfilterED #14: Patricia Hernandez, MSIV and Leyanet Gonzalez, MSIV Mar 09, 2022

Show notes

Tune in for a double feature with our Equity, Diversity and Inclusion Award winners from this fall as Nick asks them about their backgrounds, what brought them into medicine and Emergency Medicine specifically.

Patricia is a 4th year medical student at PennMed. As a first-generation immigrant, college, and medical student, she is committed to actively promoting and being an advocate for diversity, equity, and inclusion because she sees the value in having a diverse workforce to build a more equitable health care system. In diversity, there is beauty, there is growth and there is strength. Leyanet is an MS4 at Caribbean Medical University. As a Cuban refugee, she strives to facilitate better rapport & cultural sensitivity to those who are underrepresented. She believes in the importance of having a workforce paradigm that comprehensively represents the community. Leyanet aspires to be a transformational leader & be a role model for others pursuing medicine to demonstrate that shattering glass ceilings and creating an inclusive workplace is important & possible.

Podcast 762: Endocarditis Mar 08, 2022

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Variability of organisms in infecting the myocardial valves
Duke Criteria for Infective Endocarditis includes three categories that can be used to definitively diagnose endocarditis

Pathologic Criteria

pathological evidence of infection

Major Clinical Criteria

positive blood cultures
positive echocardiogram findings (TEE is more sensitive than a TTE)

Minor Clinical Criteria (must include all of the below criteria)

Fever
Underlying heart condition or IV drug use
Vascular phenomena (includes Janeway's lesions)
Immunologic phenomena (includes Osler's nodes, Roth spots)
Positive blood cultures or serologic evidence of infection with bacteria known to cause endocarditis

Some studies show up to a 33% one-year mortality of people diagnosed with endocarditis
This criteria was developed by David Durack, MD and he was affiliated with Duke University, shout out to Dr. Pete Bakes!

References

https://www.mdcalc.com/duke-criteria-infective-endocarditis

https://www.youtube.com/watch?v=3NLtNg-pqv0

Holland TL, Baddour LM, Bayer AS, Hoen B, Miro JM, Fowler VG Jr. Infective endocarditis. Nat Rev Dis Primers. 2016;2:16059. Published 2016 Sep 1. doi:10.1038/nrdp.2016.59

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

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