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 715: Heated High Flow O2 Sep 27, 2021

Show notes

Contributor: Nick Hatch, MD

Educational Pearls:

High flow nasal cannula (HFNC) or "heated high flow" can deliver higher oxygen levels than nasal cannula
It typically is used as an "intermediate" between oxygen via nasal cannula and other non-invasive positive pressure devices, such as BiPAP
Can modify both the FiO2 and flow rate
Maximum flow rate is typically 60 liters per minute (compare that to a typical breath that is 30-40 L/min)
Humidification of HFNC is important due to risk of epistaxis from drying out the nasal mucosa
Large energy expenditure to humidify airflow by a patient in respiratory distress, so humidified oxygen may help decrease this metabolic demand

References

Nishimura M. High-Flow Nasal Cannula Oxygen Therapy in Adults: Physiological Benefits, Indication, Clinical Benefits, and Adverse Effects. Respir Care. 2016;61(4):529-541. doi:10.4187/respcare.04577

Hacquin A, Perret M, Manckoundia P, et al. High-Flow Nasal Cannula Oxygenation in Older Patients with SARS-CoV-2-Related Acute Respiratory Failure. J Clin Med. 2021;10(16):3515. Published 2021 Aug 10. doi:10.3390/jcm10163515

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 714: Intradermal Sterile Water for Back Pain Sep 21, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Randomized controlled-trial evaluated intradermal injections of sterile water to manage low back pain versus an IV NSAID
Four intradermal injections of 0.1 cc sterile water in a square around the area of musculoskeletal pain
Reduction of pain was 7 points with the procedure and 2 points with the IV NSAID at 24 hours
12% in the injection group versus 50% in the IV NSAID group needed opioids
87% patient satisfaction in the injection group versus 16% patient satisfaction in the IV NSAID group

References

Tekin E, Gur A, Bayraktar M, Ozlu I, Celik BK. The effectiveness of intradermal sterile water injection for low back pain in the emergency department: A prospective, randomized controlled study. Am J Emerg Med. 2021;42:103-109. doi:10.1016/j.ajem.2021.01.038

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

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Podcast 713: Oral Ketamine Sep 20, 2021

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Those on chronic opioid therapy may have high tolerance to opioids and/or opioid hyperalgesia
Ketamine is a good adjunct for pain control in patients on chronic opioid therapy
To avoid the time constraints often required to push ketamine intravenously, it can be given orally:
- Ketamine IV 25-50 mg (~0.01-0.03 mg/kg) as a single dose by mouth

References

Blonk M, Koder B, et al. Use of oral ketamine in chronic pain management: A review. European Journal of Pain. 2009.

Schwenk ES, et al. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the America Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018.

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

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Podcast 712: Cephalosporin with a Penicillin Allergy Sep 13, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Retrospective cohort study in the Kaiser system looked at over 4 million patients receiving antibiotics to determine the effect of penicillin allergy prompts in the EHR on antibiotic prescribing
Half of the sites removed prompts stating penicillin allergy and half kept the prompts
Patients with penicillin allergies who received cephalosporins went up from 20% to 27% in areas where the prompt was remove
No difference in mortality or no new allergies found between the two groups
Reduced the use of fluoroquinolones and clindamycin in the group without the prompt

References

Macy E, McCormick TA, Adams JL, et al. Association Between Removal of a Warning Against Cephalosporin Use in Patients With Penicillin Allergy and Antibiotic Prescribing. JAMA Netw Open. 2021;4(4):e218367. Published 2021 Apr 1. doi:10.1001/jamanetworkopen.2021.8367

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

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On the Streets #10: IO Administration Gone Awry Sep 08, 2021

Show notes

Dr. Glenda Quan, trauma surgeon from Swedish Medical Center joins our host Jordan Ourada to review a case of an incorrectly placed IO and how to avoid it.

Podcast 711: Insulin Pumps Sep 07, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Insulin pumps provide a continuous infusion of fast-acting insulin using a basal rate and bolus prior to meals
Some connect to a continuous glucometer but often blood glucose needs to be checked manually
Hypoglycemia is rarely due to a malfunctioning pump - there is usually an another external factor
Hyperglycemia can be caused by underdosing, illness, pump malfunction or expired insulin
The pump can be used to give a bolus of insulin in the emergency department if necessary
Stopping the device can be done manually on the device or disconnecting it from the tubing attachment - do not remove the tubing from the skin site if possible

References

Nimri R, Nir J, Phillip M. Insulin Pump Therapy. Am J Ther. 2020;27(1):e30-e41. doi:10.1097/MJT.0000000000001097

Sora ND, Shashpal F, Bond EA, Jenkins AJ. Insulin Pumps: Review of Technological Advancement in Diabetes Management. Am J Med Sci. 2019;358(5):326-331. doi:10.1016/j.amjms.2019.08.008

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

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Podcast 710: Droperidol vs. Zyprexa Aug 31, 2021

Show notes

Contributor: Nick Tsipis, MD

Educational Pearls:

Prospective trial studied 5 mg IM droperidol to 10 mg IM olanzapine (Zyprexa) in the reducing levels of agitation
Time to adequate sedation was about 16 minutes for both agents
Droperidol was slightly less sedating than olanzapine and length of stay for olanzapine was longer
Olanzapine had a higher rate of requiring another agent for adequate sedation
Droperidol had a higher rate of adverse events (mainly extrapyramidal symptoms) than olanzapine
Remember to put the safety of the staff and patient at the forefront of sedation practices and be cognizant of the psychological effect of giving involuntary medications to patients

References

Cole JB, Stang JL, DeVries PA, Martel ML, Miner JR, Driver BE. A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages. Ann Emerg Med. 2021;78(2):274-286. doi:10.1016/j.annemergmed.2021.01.005

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

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Podcast 709: Clown Therapy Aug 30, 2021

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Using LET, procedural sedation, and distraction techniques are often needed to successfully perform painful procedures in pediatrics patients
The technique of clown therapy has been studied as an adjunct to LET and other distraction techniques for procedures in pediatric patients
One randomized-controlled trial from 2016 found anxiety was greatly reduced using medical clown therapy to aid in painful procedures in pediatrics patients

References

Felluga M, Rabach I, Minute M, et al. A quasi randomized-controlled trial to evaluate the effectiveness of clowntherapy on children's anxiety and pain levels in emergency department. Eur J Pediatr. 2016;175(5):645-650. doi:10.1007/s00431-015-2688-0

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

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Podcast 708: Diagnostic Paracentesis Aug 24, 2021

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

Paracentesis is a procedure where fluid is removed from the peritoneal cavity by needle
Indications for paracentesis include: large volume paracentesis (5-6L), diagnosis of transudative or exudative ascites, evaluation for spontaneous bacterial peritonitis (SBP)
Infection of ascitic fluid is more likely in transudative processes due to the increased frequency of paracentesis
E coli is the most common pathogen to cause SBP
Treatment with 3rd generation cephalosporin, like ceftriaxone

References

Aponte EM, Katta S, O'Rourke MC. Paracentesis. [Updated 2020 Sep 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK435998/

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

Podcast 707: Sigmoid Volvulus Aug 23, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Sigmoid volvulus occurs when the sigmoid colon twists 180 to 360 degrees
10% of intestinal obstructions in the US; 50-70% of intestinal obstructions worldwide
More common in elderly patients with chronic constipation
Eventually may lead to bowel perforation, a surgical emergency
Treatment is sigmoidoscopy or sigmoid colectomy

References

Lieske B, Antunes C. Sigmoid Volvulus. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441925/

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

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