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 733: Nitric Oxide for COVID Nov 30, 2021

Show notes

Contributor: Nick Hatch, MD

Educational Pearls:

Inhaled nitric oxide or Flolan may be considered in COVID
- Flolan is a prostaglandin can be inhaled or given IV
These medications are classically used for right-sided heart failure, but may be used in COVID
Causes pulmonary vasodilation to reduce the resistance against the right ventricle
Complications include hypotension and hemolysis, but nitric oxide can be turned off very quickly if needed
- Be careful and wean patients on nitric oxide for pulmonary hypertension

References

Lotz C, Muellenbach RM, Meybohm P, et al. Effects of inhaled nitric oxide in COVID-19-induced ARDS - Is it worthwhile?. Acta Anaesthesiol Scand. 2021;65(5):629-632. doi:10.1111/aas.13757

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 732: Organophosphate Toxicity Nov 23, 2021

Show notes

Educational Pearls:

Organophosphates affect the cholinergic system by inhibiting acetylcholinesterase affecting muscarinic and nicotinic receptors
Symptoms include lacrimation, salivation, bronchoconstriction, blurred vision, bradycardia, bronchorrhea, emesis, and diarrhea
Initially, the patient should be decontaminated to prevent further organophosphate exposure
Treatment consists of atropine every 5 minutes, 1-3 mg to start and doubling the dose each time it is given until reversal of symptoms is seen
Atropine only works on muscarinic receptors, so nicotinic receptor activation continues despite atropine administration resulting in muscle contractions and eventually respiratory arrest
Pralidoxime (2-PAM) should also be given to prevent the nicotinic effects and maturation of the organophosphate-acetylcholinesterase complex

References

Robb EL, Baker MB. Organophosphate Toxicity. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470430/

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

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Podcast 731: Fluid Resuscitation in Burns Nov 22, 2021

Show notes

Contributor: Chris Holmes, MD

Educational Pearls:

Parkland Formula: 4 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours
- 50% given over 8 hours and 50% given over the next 16 hours
Brooke Formula: 2 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours
- 50% given over 8 hours and 50% given over the next 16 hours
2009 military study evaluated Parkland vs. Brooke formulas for severe burn patients and found the outcomes were the same
Guidelines are in flux on which formula to use, but reducing the overall volume using the Brooke formula can be done without significant change in morbidity or mortality
Using fluid responsiveness by measuring urine output and signs of fluid overload can help guide overall resuscitative approach in burn patients

References

Chung KK, Wolf SE, Cancio LC, et al. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009;67(2):231-237. doi:10.1097/TA.0b013e3181ac68cf

Schaefer TJ, Nunez Lopez O. Burn Resuscitation And Management. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430795/

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

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Podcast 730: Alternative Treatment for Gonorrhea Nov 16, 2021

Show notes

Educational Pearls:

Recent updates to treatment guidelines increased the 250 mg ceftriaxone IM dose to 500 mg ceftriaxone IM
IM dosing can be very painful, so other methods of administration can help decrease pain for patients
Using IV ceftriaxone instead of IM has no significant difference in pharmacokinetics or bioavailability, so it can be considered in patients with an IV already placed

References

St Cyr S, Barbee L, Workowski KA, et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-1916. Published 2020 Dec 18. doi:10.15585/mmwr.mm6950a6

Product Information: ROCEPHIN(R) IV, IM injection, ceftriaxone sodium IV, IM injection. Genentech USA, Inc. (per Manufacturer), South San Francisco, CA, 2010.

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

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Podcast 729: Molnupiravir for COVID Nov 15, 2021

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

A press release from Merck introduced Molnupiravir for treatment of mild to moderate COVID-19
The yet to be published study is a randomized control trial at around 100 different sites
Reported outcomes were hospitalization and mortality from COVID and mortality from COVID
Molnupiravir was found to be twice as effective as placebo looking at these two endpoints (7% vs. 14%)
5 day course of the drug taken twice per day costs $700, but cost-saved from using this drug was $32,000 per patient

References

https://www.merck.com/news/merck-and-ridgebacks-investigational-oral-antiviral-molnupiravir-reduced-the-risk-of-hospitalization-or-death-by-approximately-50-percent-compared-to-placebo-for-patients-with-mild-or-moderat/

https://www.merck.com/news/merck-and-ridgebacks-molnupiravir-an-oral-covid-19-antiviral-medicine-receives-first-authorization-in-the-world/

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

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Podcast 728: Angiography for Out-of-Hospital Cardiac Arrest without ST Elevation Nov 09, 2021

Show notes

Contributor: Nick Tsipis, MD

Educational Pearls:

Meaningful survival under 10% for out of hospital cardiac arrest
The most common cause of out-of-hospital cardiac arrest is due to cardiac ischemia
Study looked at whether taking patients without ST elevation who had an out-of-hospital cardiac arrest with return of spontaneous circulation (ROSC) should receive angiography upon arrival to the hospital
Took 530 patients and randomized to early vs. delayed angiography after resuscitation from out-of-hospital arrest
Found no benefit to early angiography using 30-day all-cause risk of death as the primary endpoint

References

Desch S, Freund A, Akin I, et al. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation [published online ahead of print, 2021 Aug 29]. N Engl J Med. 2021;10.1056/NEJMoa2101909. doi:10.1056/NEJMoa2101909

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

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Podcast 727: Antibiotics for Diverticulitis Nov 08, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Classically, diverticulitis is diagnosed via CT scan and patients are discharged home on antibiotics if they are without complication
The DINAMO study is a multicenter open-label RCT that evaluated if it is safe to not give antibiotics to patients with mild acute diverticulitis
Found no difference in readmission, return visits to ED, pain control, or likelihood of surgical intervention between the group that was sent home with antibiotics and the group without
Medical societies have not reached a consensus on this issue, likely further studies need to be completed

References

Mora-López L, Ruiz-Edo N, Estrada-Ferrer O, et al. Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study): A Multicentre, Randomised, Open-label, Noninferiority Trial. Ann Surg. 2021;274(5):e435-e442. doi:10.1097/SLA.0000000000005031

*Image from Hellerhoff, CC BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

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

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Podcast 726: Ophthalmia Neonatorum Nov 02, 2021

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

Ophthalmia Neonatorum encompasses any conjunctivitis that presents within the first 28 days of life
Neonates often receive prophylactic silver nitrate eye drops for gonorrhea prophylaxis, but the drops can cause chemical conjunctivitis
Etiology & Timing of Presentation:
- Silver nitrate conjunctivitis presents 0-2 days after birth
- Neisseria gonorrhae presents 2-5 days after birth
- Chlamydia trachomatis presents 5 days to 5 weeks
Neisseria gonorrhoeae conjunctivitis is vision-threatening, typically requiring admission and IV antibiotics with a 3rd generation cephalosporin

References

Castro Ochoa KJ, Mendez MD. Ophthalmia Neonatorum. [Updated 2021 Jul 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551572/

US Preventive Services Task Force, Curry SJ, Krist AH, et al. Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA. 2019;321(4):394-398. doi:10.1001/jama.2018.21367

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

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Podcast 725: Hypothermia in Preterm Deliveries Nov 01, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Preterm deliveries in the ED can be complex and preventing hypothermia is essential to the health of the baby
Recent meta-analysis examined methods for warming preterm deliveries to prevent hypothermia
The most effective way to warm the baby is by wrapping them in plastic

References

Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, et al. Delivery Room Interventions for Hypothermia in Preterm Neonates: A Systematic Review and Network Meta-analysis. JAMA Pediatr. 2021;175(9):e210775. doi:10.1001/jamapediatrics.2021.0775

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

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Podcast 724: Ivermectin Overdose Oct 26, 2021

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Ivermectin is a Nobel-Prize winning antiparasitic used to treat filariasis and onchocerciasis
Ivermectin is receiving press due to a scientific study examining ivermectin on COVID-19 viral replication in vitro, but the dosages needed for this effect were much higher than is safe for human use
Ivermectin has since been studied in humans with no evidence suggesting it is a viable treatment for COVID-19
Ivermectin is a neurotoxin but at normal levels it does not cross the blood-brain barrier
Ivermectin toxicity can include altered mental status, seizures, coma, tachycardia, hypotension, nausea, vomiting and diarrhea
Treatment of suspected ivermectin overdose is predominately supportive

References

Caly L., Druce J.D., Catton M.G., Jans D.A., Wagstaff K.M. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antivir Res. 2020;178:104787. doi: 10.1016/j.antiviral.2020.104787

López-Medina E, López P, Hurtado IC, et al. Effect of Ivermectin on Time to Resolution of Symptoms Among Adults With Mild COVID-19: A Randomized Clinical Trial. JAMA. 2021;325(14):1426–1435. doi:10.1001/jama.2021.3071

Roder JD, Stair EL. An overview of ivermectin toxicosis. Vet Hum Toxicol. 1998;40(6):369-370.

Roman YM, Burela PA, Pasupuleti V, Piscoya A, Vidal JE, Hernandez AV. Ivermectin for the treatment of COVID-19: A systematic review and meta-analysis of randomized controlled trials [published online ahead of print, 2021 Jun 28]. Clin Infect Dis. 2021;ciab591. doi:10.1093/cid/ciab591

Chandler RE. Serious Neurological Adverse Events after Ivermectin-Do They Occur beyond the Indication of Onchocerciasis?. Am J Trop Med Hyg. 2018;98(2):382-388. doi:10.4269/ajtmh.17-0042

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

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