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 752: Budesonide for COVID Feb 01, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Recent study evaluated budesonide for outpatient COVID-19 infection treatment to see if there was a decrease in length of illness or hospitalization rates
Found patients who received a budesonide inhaler had recovery times that were about 3 days shorter and there was a slight (non-significant) decrease in hospitalizations

References

Berezowski I, Patel J, Shaw M, Pourmand A. High-dose budesonide for early COVID-19. Lancet. 2021;398(10317):2146-2147. doi:10.1016/S0140-6736(21)02441-7

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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Podcast 751: The Bougie Trial Jan 31, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

An endotracheal tube introducer or bougie are often used as a rescue device during difficult intubations as they are small and can be placed blindly
Large randomized-controlled trial looked at first-pass bougie use versus standard intubation to determine if there was improvement in first-pass success rate
No difference in first-pass success rate, about 80% for both techniques
This does not mean that bougies are not great rescue devices or options for managing an airway

References

Driver BE, Semler MW, Self WH, et al. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA. 2021;326(24):2488–2497.

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

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Mental Health Monthly #9: Suicide Assessment in the ED: Using the ICAR2E Tool Jan 26, 2022

Show notes

Dr. Kim Nordstrom discusses a valuable bedside tool for evidence-based assessment in patients that visit the ED and are at risk for suicidality. Dr. Nordstrom is a practicing emergency psychiatrist and associate professor with the University of Colorado. As a developer and user of the tool, Dr. Nordstrom gives us invaluable insight into a new avenue for psychiatric care in emergency medicine.

Educational Pearls:

An app-based tool made in conjunction with ACEP
Identifying suicidal risk for each patient, including assessment of clues like bodily injuries
Communicating with patients to create a safe space and enhance rapport
Assessing for threats such as environmental or personal objects
Risk assessment; previous attempts, mental state, life stressors, etc.
Risk reduction once discharge is thought possible
Extension of care once patients leave the ED

Link to Access the ICAR2E Tool

References

Wilson MP, Moutier C, et al. Emergency department recommendations for suicide prevention in adults: The ICAR2E mnemonic and a systematic review of the literature. Am J Emerg Med. 2020; 38:571-581.

Summarized by Jorge Chalit

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Podcast 750: Take Home Naloxone Jan 25, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Think about giving take home naloxone kits for anyone on long-term opioids as well as anyone with an opioid use disorder, those in opioid withdrawal, or those who recently overdosed on opioids
Also consider for individuals with non-opioid substance use disorders
For patients seen in the ED with an opioid overdose the 1-year mortality is about 5% and 1-month mortality is about 1%
Also 50% of accidental pediatric overdose deaths are due to opioids, so ensuring naloxone is present in the household can save lives
Prescriptions have a very low fill rate, so getting naloxone in the hands of people before they leave is important

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. doi:10.1007/s40265-019-01154-5

Katzman JG, Takeda MY, Greenberg N, et al. Association of Take-Home Naloxone and Opioid Overdose Reversals Performed by Patients in an Opioid Treatment Program. JAMA Netw Open. 2020;3(2):e200117. Published 2020 Feb 5. doi:10.1001/jamanetworkopen.2020.0117

Weiner SG, Baker O, Bernson D, Schuur JD. One-Year Mortality of Patients After Emergency Department Treatment for Nonfatal Opioid Overdose. Ann Emerg Med. 2020;75(1):13-17. doi:10.1016/j.annemergmed.2019.04.020

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

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Podcast 749: PCC for Me? Jan 24, 2022

Show notes

Contributor: Nick Tsipis, MD

Educational Pearls:

Prothrombin complex concentrate (Kcentra) and Vitamin K are used to reverse life-threatening bleeds in patients on warfarin (Coumadin)
Factors II, VII, IX, and X are included in four-factor PCC
PCC/Kcentra dosing is 500-2000 units based on INR and patient weight
PROPER3 RCT was a non-inferiority trial done to evaluate standardized dosing of PCC/Kcentra versus variable dosing based on INR and weight
Looked at end-points to assess hemostasis, but ultimately this trial did not show non-inferiority of standardized dosing compared to variable dosing

References

Abdoellakhan RA, Khorsand N, Ter Avest E, et al. Fixed Versus Variable Dosing of Prothrombin Complex Concentrate for Bleeding Complications of Vitamin K Antagonists-The PROPER3 Randomized Clinical Trial. Ann Emerg Med. 2022;79(1):20-30. doi:10.1016/j.annemergmed.2021.06.016

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

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Podcast 748: Botulism Jan 18, 2022

Show notes

Contributor: Nick Hatch, MD

Educational Pearls:

Botulism requires a prompt clinical diagnosis as lab results can take about 5 days to return
Whale blubber, honey, home fermented foods, homemade wine (especially the wine made in prison), and improperly stored canned food can all contain the toxin
The botulinum toxin is create by a Clostridium botulinum that is prevalent on our food and in the soil, but the toxin is readily degraded with heat and light
Blocks release of acetylcholine at the neuromuscular junction preventing release of neurotransmitter and therefore the propagation of an electrical nerve potential
Descending paralysis, often first including bulbar muscles, and anticholinergic symptoms can be present on exam
Infantile botulism, classically seen as floppy baby syndrome, occurs up to a week after ingestion, because the infant GI tract is not acidic enough to deactivate the toxin
Antitoxin is available to neutralize the botulism toxin present, but it cannot prevent the already established symptoms

References

Jeffery IA, Karim S. Botulism. [Updated 2021 Jul 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459273/

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

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Podcast 747: Food Impaction Jan 17, 2022

Show notes

Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Esophageal food impaction can be managed in the ED prior to calling GI for endoscopy
Coca-cola, glucagon, benzodiazepines, calcium channel blockers, and dissolved nitroglycerin are all options to try
For pediatric patients, weighted bougies can be used under sedation to attempt retrieval of the food bolus
Always evaluate airway status, especially if the patient cannot maintain secretions

References

Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J Emerg Med. 2019;56(5):499-511. doi:10.1016/j.jemermed.2019.01.025

Khayyat YM. Pharmacological management of esophageal food bolus impaction. Emerg Med Int. 2013;2013:924015. doi:10.1155/2013/924015

Schimmel J, Slauson S. Swallowed Nitroglycerin to Treat Esophageal Food Impaction. Ann Emerg Med. 2019;74(3):462-463. doi:10.1016/j.annemergmed.2019.04.003

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

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Podcast 746: Elderly Head Trauma on Anticoagulation Jan 11, 2022

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Biggest study to date examined new protocol for repeat head CT in anticoagulated elderly patients with head trauma and an initial negative head CT
- 0.5%-6% of patients in this category will get a delayed ICH and this can occur up to a week out from initial injury
18% of the study group had an ICH on initial head CT, but the rest who had negative head CT initially received a repeat head CT at 6 hours
0.9% had a bleed identified on repeat head CT 6 hours after initial imaging, but of this group no one had an intervention for this bleed
Suggests repeat head CT may not be needed and that good counseling for return precautions and discharge is a reasonable disposition in caring for these patients
Supratherapeutic INR was a risk factor for delayed bleed, so they should be treated as a higher risk group of patients

References

Borst J, Godat LN, Berndtson AE, Kobayashi L, Doucet JJ, Costantini TW. Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective. Surgery. 2021;170(2):623-627. doi:10.1016/j.surg.2021.02.024

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

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Podcast 745: Nitrous-Induced B12 Deficiency Jan 10, 2022

Show notes

Contributor: Alicia Oberle, MD

Educational Pearls:

Nitrous oxide (N2O) can cause a vitamin B12 deficiency in patients after regular use
N2O is used in procedural sedation but also as a popular recreational drug
N2O binds and inactivate B12 in the body, therefore decreasing usable supply
Lack of B12, which is essential for myelinating nerves, can lead to subacute combined degeneration of the spinal cord
Presentation may include paresthesias, ataxia, gait changes, or bilateral lower extremity motor weakness
B12 can be normal on labs, as the B12 is present but inactivated
Treatment is daily B12 injections and oral supplementation

References

Stockton L, Simonsen C, Seago S. Nitrous oxide-induced vitamin B12 deficiency. Proc (Bayl Univ Med Cent). 2017;30(2):171-172. doi:10.1080/08998280.2017.11929571

Samia AM, Nenow J, Price D. Subacute Combined Degeneration Secondary to Nitrous Oxide Abuse: Quantification of Use With Patient Follow-up. Cureus. 2020;12(10):e11041. Published 2020 Oct 19. doi:10.7759/cureus.11041

Edigin E, Ajiboye O, Nathani A. Nitrous Oxide-induced B12 Deficiency Presenting With Myeloneuropathy. Cureus. 2019;11(8):e5331. Published 2019 Aug 6. doi:10.7759/cureus.5331

*Image obtained from Wikimedia author Hansmuller and licensed under Creative Commons Attribution-Share Alike 4.0 International license.

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

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Podcast 744: Glucagon for Beta Blocker Toxicity Jan 04, 2022

Show notes

Educational Pearls:

Glucagon can be used to treat hypoglycemia and esophageal foreign body, but it can also be used in beta-blocker toxicity to bypass cardiac beta-blockade
The superior option for treating bradycardia due to beta-blocker toxicity is glucagon
Glucagon has decreased efficacy in patients with heart failure, so increased doses up to 10 mg might be required in the event of beta-blocker toxicity

References

Khalid MM, Galuska MA, Hamilton RJ. Beta-Blocker Toxicity. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448097/

Rotella JA, Greene SL, Koutsogiannis Z, et al. Treatment for beta-blocker poisoning: a systematic review. Clin Toxicol (Phila). 2020;58(10):943-983. doi:10.1080/15563650.2020.1752918

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

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