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 723: Nitro Drip in Flash Pulmonary Edema Oct 25, 2021

Show notes

Contributor: Alec Coston, MD

Educational Pearls:

Flash pulmonary edema or Sympathetic Crash Acute Pulmonary Edema (SCAPE) is a severe illness that requires aggressive treatment
Often in patients with heart failure and a sympathetic surge increasing heart rate, decreased diastolic filling, increased preload, and increased afterload causing pulmonary edema
Clinical diagnosis: acute onset diaphoresis and respiratory distress, hypoxia and tachypnea on exam
Bedside lung ultrasound will demonstrate B-lines, indicative of pulmonary edema
Treatment is nitroglycerin and BiPAP
Nitroglycerin drip can be started at 80 micrograms/minute, which is similar to the dose delivered by sublingual nitroglycerin

References

Stemple K, DeWitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series. Am J Emerg Med. 2021;44:262-266. doi:10.1016/j.ajem.2020.03.062

Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719-723. doi:10.4103/0972-5229.195710

Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-131. doi:10.1016/j.ajem.2016.10.038

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.

Donate to EMM today!

On the Streets #12: Salient Pre-hospital Considerations for Neurosurgical Emergencies - a Smorgasbord Part II Oct 20, 2021

Show notes

In this podcast, we are back again with host, Jordan Ourada, and neurosurgeon, Dr. Eddie Tsvankin as they discuss an exciting and mind-blowing array of topics pertaining to neurosurgery. Listen as Dr. Tsvankin shares his views on not only the history of neurosurgery, but also the medical, surgical, and engineering advancements that are taking place today. You'll also hear Dr. Tsvankin give intriguing details into how neurosurgeries are performed with cutting-edge technology including the exoscopes that are presently utilized at Swedish Medical Center. Finally, Jordan and Dr. Tsvankin delve into predictions for future advancements in neurosurgery and neurooncology, as well as why cancer seems more prevalent today than ever.

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Diversity and Inclusion Award

Podcast 722: Lower Extremity Dislocations Oct 19, 2021

Show notes

Contributor: Donald Stader, MD

Educational Pearls:

Hip Dislocation
- Prolonged dislocations can impair blood supply to femoral head
- Hip dislocation for >6 hours puts patient at high risk for needing a hip replacement in the next two year
Knee Dislocation
- High mechanism
- Often looks anatomically normal on knee x-ray
- Vascular injuries of the popliteal artery can cause significant morbidity with some studies suggesting an 80% amputation rate if not treated within 6 hours
Ankle Dislocation
- Common dislocation and often co-occurs with ankle fractures (bimalleolar/trimalleolar)
- Pressure on the skin from the displaced joint can cause skin tenting, which can lead to skin necrosis
- Hematoma blocks work well for ankle reductions as an adjunct to or substitute for procedural sedation

References

Arnold C, Fayos Z, Bruner D, Arnold D. Managing dislocations of the hip, knee, and ankle in the emergency department. Emerg Med Pract. 2017;19(12):1-28.

Dawson-Amoah K, Raszewski J, Duplantier N, Waddell BS. Dislocation of the Hip: A Review of Types, Causes, and Treatment. Ochsner J. 2018;18(3):242-252. doi:10.31486/toj.17.0079

Patterson BM, Agel J, Swiontkowski MF, Mackenzie EJ, Bosse MJ; LEAP Study Group. Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma. 2007;63(4):855-858. doi:10.1097/TA.0b013e31806915a7

Ross A, Catanzariti AR, Mendicino RW. The hematoma block: a simple, effective technique for closed reduction of ankle fracture dislocations. J Foot Ankle Surg. 2011;50(4):507-509. doi:10.1053/j.jfas.2011.04.037

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

Podcast 721: Blakemore & Minnesota Tubes: Part II Oct 18, 2021

Show notes

Contributor: Dylan Luyten, MD

Educational Pearls:

To place a Blakemore/Minnesota Tube:
- Insert into esophagus under visualization
- Inflate gastric port with 60 cc of air and obtain a chest xray to ensure the balloon below the diaphragm
- Once confirmed, place a total of 500cc of air into the gastric balloon via the gastric port
- Tie a liter saline bad to the tube using Kerlix and hang it off an IV pole or other object to provide about 2 lbs of traction
- Now the the tube is in place under traction, attach a manometer to the esophageal balloon port
- Provide low pressure to tamponade a variceal bleed, which is about 33 mmHg
This is a temporizing measure and often patients need to get a Transjugular Intrahepatic Portosystemic Shunt (TIPS) from interventional radiology for more definitive treatment

References

Powell M, Journey JD. Sengstaken-Blakemore Tube. [Updated 2021 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558924/

Amazing video of placement by EM:RAP ProductionsPlacement of a Minnesota Tube for Bleeding Varices

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

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On the Streets #11: Salient Pre-hospital Considerations for Neurosurgical Emergencies - a Smorgasbord Oct 13, 2021

Show notes

On this episode of On The Streets, host, Jordan Ourada sits down with neurosurgeon/neurooncologist Dr. Eddie Tsvankin to discuss various topics concerning neurosurgery and how EMS workers in the field can better understand and manage neurological emergencies. In this episode specifically, you'll hear Jordan and Dr. Tsvankin discuss topics including:

Priorities in caring for patients experiencing seizures
Short and long-term complications of tumor resection surgery
Specifics on how brain tumors are operated on and the difficult decisions that must be made ahead of time
Assessment of post-operative incisions and signs of infections
How chemotherapy and radiation effect the healing process for neurosurgery patients
Dr. Eddie's thoughts on COVID and how it has impacted his career
The ins and outs of ventriculoperitoneal shunts

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Diversity and Inclusion Award

Podcast 720: Blakemore & Minnesota Tubes: Part I Oct 12, 2021

Show notes

Contributor: Dylan Luyten, MD

Educational Pearls:

Minnesota Tube has an extra port for suctioning otherwise is the same as a Blakemore Tube
Indicated in MASSIVE upper GI bleeding often due to esophageal varices
Esophageal varices are dilated, tortuous vessels in the esophagus due to increased portal venous pressure that can bleeding into the upper GI tract
Patients with massive upper GI bleed should be intubated prior to placing a Blakemore/Minnesota tube

References

Meseeha M, Attia M. Esophageal Varices. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448078/

Biecker E. Portal hypertension and gastrointestinal bleeding: diagnosis, prevention and management. World J Gastroenterol. 2013;19(31):5035-5050. doi:10.3748/wjg.v19.i31.5035

Photo from Wikimedia Commons

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

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Check out our Diversity and Inclusion Award

Podcast 719: Normal Saline vs. Tap Water for Wound Irrigation Oct 11, 2021

Show notes

Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Multiple RCTs and a Cochrane Review found there is no difference in wound infection rates when irrigating with tap water
Pressure of the water and how extensively the wound is irrigated were the most important factors affecting infection rates
Quantity and type of water were independently not as important

References

Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012;(2):CD003861. Published 2012 Feb 15. doi:10.1002/14651858.CD003861.pub3

Lewis K, Pay JL. Wound Irrigation. [Updated 2021 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538522/

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

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Podcast 718: Renal Failure Follow Up Oct 05, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Patients with acute renal failure often need medical management for hyperkalemia
Those with severe electrolyte derangements or absent renal function may need emergent dialysis as well
Dialysis catheters are 12 or 14 french catheters placed in the right internal jugular or left subclavian
Placement is very similar to a central line or cordis catheter
Trialysis catheter is one option that has an extra port that can be used for regular medication administration and drawing blood
Do not default to use dialysis catheters for normal ED access due to risk of infection and clot development
While dialysis catheters are typically reserved for dialysis only, they can be used in extreme circumstances, such as a cardiac arrest

References

Co I, Gunnerson K. Emergency Department Management of Acute Kidney Injury, Electrolyte Abnormalities, and Renal Replacement Therapy in the Critically Ill. Emerg Med Clin North Am. 2019;37(3):459-471. doi:10.1016/j.emc.2019.04.006

Simon LV, Hashmi MF, Farrell MW. Hyperkalemia. [Updated 2021 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470284/

Akaraborworn O. A review in emergency central venous catheterization. Chin J Traumatol. 2017;20(3):137-140. doi:10.1016/j.cjtee.2017.03.003

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

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Podcast 717: A cautionary tale of renal failure Oct 04, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Hyperkalemia can cause EKG changes such as a widened QRS
The fastest electrolyte results can be obtained off a VBG with electrolytes or point-of-care labs
Hyperkalemia may be reported as "hemolyzed" which indicated lysis of red blood cells and artificial elevation of the potassium level. However, always keep in mind the clinical context and look at other metabolic abnormalities like creatinine and BUN for other clues that it may actually not be hemolyzed

References

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

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Podcast 716: Resuscitation Fluids Sep 29, 2021

Show notes

Contributor: Nick Tsipis, MD

Educational Pearls:

Fluid choice may have an impact on outcomes in resuscitation, and a meta-analysis has relevant insight into their use in sepsis and trauma patients
Large volume normal saline fluid resuscitation in sepsis is associated with acute kidney injury and metabolic acidosis compared to Lactated Ringers
Choice of fluid did not have significant differences in trauma patients for initial resuscitation

References

Tseng CH, Chen TT, Wu MY, Chan MC, Shih MC, Tu YK. Resuscitation fluid types in sepsis, surgical, and trauma patients: a systematic review and sequential network meta-analyses. Crit Care. 2020;24(1):693. Published 2020 Dec 14. doi:10.1186/s13054-020-03419-y

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