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 697: Kounis Syndrome Jul 26, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Kounis syndrome is an allergic acute coronary syndrome
Triggers include medications (antibiotics), insect bites, or other common allergens
Believed to be due to mast cell activation, inflammatory cytokines, and platelet activation causing coronary vasospasm or plaque rupture in setting of existing atherosclerosis
Consider Kounis syndrome in the setting of chest pain in anaphylaxis
Treatment involves treatment of allergic reaction, although epinephrine should be used cautiously
Avoid morphine as this can cause mast cell activation

References

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!

Podcast 696: ST Elevation and Differential Diagnoses Jul 21, 2021

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

ST elevation clinical guidelines for myocardial infarction include:
- 2.5 mm elevation for males
- 2 mm elevation in males >40 in V2 and V3
- 1.5 mm elevation for females in V2 and V3
- 1 mm elevation in 2 or more contiguous leads (not V2 or V3)
Differential diagnosis of ST elevation includes, but is not limited to:
- STEMI
- Electrolyte abnormalities
- Pericarditis/myocarditis
- Brugada syndrome
- LVH
- Bundle branch blocks
- Ventricular aneurysm

References

de Bliek EC. ST elevation: Differential diagnosis and caveats. A comprehensive review to help distinguish ST elevation myocardial infarction from nonischemic etiologies of ST elevation. Turk J Emerg Med. 2018;18(1):1-10. Published 2018 Feb 17. doi:10.1016/j.tjem.2018.01.008

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 www.emergencymedicalminute.org/cme-courses/ and create an account.

Donate to EMM today!

Podcast 695: Einstein and Cellophane Jul 20, 2021

Show notes

Educational Pearls:

Albert Einstein had chronic abdominal pain as a middle-aged man
Dr. Rudolph Nissen, founder of the Nissen fundoplication, performed exploratory surgery for this pain and found an abdominal aortic aneurysm (AAA)
The only treatment for an AAA at that time was to wrap the vessel in cellophane, causing a fibrotic response to prevent rupture
Einstein died 7 years after this surgery, likely from his leaking abdominal aortic aneurysm

References

Cervantes Castro J. Albert Einstein y su aneurisma de la aorta [Albert Einstein and his abdominal aortic aneurysm]. Gac Med Mex. 2011;147(1):74-76.

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 www.emergencymedicalminute.org/cme-courses/ and create an account.

Donate to EMM today!

Podcast 694: Complete Heart Block Jul 19, 2021

Show notes

Contributor: Nick Hatch, MD

Educational Pearls:

Complete heart block or 3rd degree atrioventricular (AV) block is diagnosed via EKG and occurs when electrical signals from the sinoatrial (SA) node are blocked from reaching the ventricles via the AV node and AV bundles
P waves and QRS complexes are independent
Often QRS rate is around 40
The rate is slow because the ventricular purkinje fibers have an intrinsic rate of 20-40 bpm, whereas the SA node has an intrinsic rate of 60-100 bpm
Treatment is usually with pacemaker, unless there is an identifiable etiology causing the heart block that can be reversed

References

Knabben V, Chhabra L, Slane M. Third-Degree Atrioventricular Block. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545199/

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 www.emergencymedicalminute.org/cme-courses/ and create an account.

Donate to EMM today!

Podcast 693: Humerus Fractures Jul 14, 2021

Show notes

Contributor: Nick Tsipis, MD

Educational Pearls:

Humerus fractures can be characterized as proximal, midshaft, and distal fractures
Proximal humerus fracture is the second-most common fracture in elderly patients
- Primary complication is with the axillary nerve and axillary artery
- Vast majority are managed nonoperatively with a sling, reduction usually not indicated
- Women comprise 70% of proximal humerus fractures, often secondary to fall with osteoporosis
Midshaft humerus fractures are more often managed operatively, but can be managed nonoperatively
- Primary complication is with radial nerve, look for wrist drop!
- May require reduction and splinting
Distal humerus fractures can include supracondylar fractures and involve the radius or ulna
- One atypical is the Holstein-Lewis fracture, that can cause radial nerve damage
- Management is varied depending on the exact type of distal humerus fracture
Assess degree of angulation, neurovascular status, and likelihood of compartment syndrome both before and after splint application

References

Attum B, Thompson JH. Humerus Fractures Overview. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482281/

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 www.emergencymedicalminute.org/cme-courses/ and create an account.

Donate to EMM today!

Podcast 692: Pelvic Fractures Jul 13, 2021

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

Pelvis is comprised of the iliac, ischium, and sacrum
Three mechanisms for pelvic fractures by Young-Burgess Classification
- Anterior-posterior compression causing open-book pelvic fractures that can be complicated by retroperitoneal bleeding or urethral injury
- Lateral compression causing rami fractures
- Vertical sheer causing offset of sacroiliac joint or sacrum
Mechanically stable pelvic ring fractures can be conservatively treated with weight bearing as tolerated
Unstable fractures and those with complications will require operative fixation

References

Davis DD, Foris LA, Kane SM, et al. Pelvic Fracture. [Updated 2021 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430734/

Weatherford B. Pelvic Ring Fractures. OrthoBullets. Updated 25 May 2021. https://www.orthobullets.com/trauma/1030/pelvic-ring-fractures

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 www.emergencymedicalminute.org/cme-courses/ and create an account.

Donate to EMM today!

Podcast 691: TXA in Head Bleeds Jul 12, 2021

Show notes

Contributor: Ricky Dhaliwal, MD

Educational Pearls:

CRASH 3 Trial looked at over 12,000 patients with traumatic intracranial bleeds, randomizing patients to a therapy with TXA or standard of care without TXA
Dosing was 1 gram over 10 min for loading dose and then an infusion of 1 gram over 8 hours
Found Improvement in survival and neurologic outcomes when patient received TXA within 3 hours

References

CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial [published correction appears in Lancet. 2019 Nov 9;394(10210):1712]. Lancet. 2019;394(10210):1713-1723. doi:10.1016/S0140-6736(19)32233-0

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 www.emergencymedicalminute.org/cme-courses/ and create an account.

Donate to EMM today!

Podcast 690: Rectal Oxygen. Nice, Jul 07, 2021

Show notes

Contributor: Chris Holmes, MD

Educational Pearls:

In the 1700s, boxes lined the River Thames to pump smoke up the rectum to resuscitate people who had been found unconscious in the river
Sea cucumbers can extract oxygen through their rectum
Perflourocarbon, a liquid that can become oxygenated, provided rectally was able to oxygenate pigs and mice in a recent study

References

Okabe R, Chen-Yoshikawa T, Yoneyama Y, et al. Mammalian enteral ventilation ameliorates respiratory failure. Clinical and Translational Resource and Technology Insights. 2021;2(6):773-783. doi:https://doi.org/10.1016/j.medj.2021.04.004

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 www.emergencymedicalminute.org/cme-courses/ and create an account.

Donate to EMM today!

Podcast 689: Peri-Intubation Hypotension Jul 06, 2021

Show notes

Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Hypotension in patients requiring intubation should be resuscitated as much as possible
While intubating, the negative inspiratory pressure goes away decreasing cardiac preload and worsening hypotension
Phenylephrine can be given via push doses to increase blood pressure from alpha agonism
For sedation, avoid propofol with hypotension and opt for etomidate or ketamine

References

April MD, Arana A, Schauer SG, et al. Ketamine Versus Etomidate and Peri-intubation Hypotension: A National Emergency Airway Registry Study. Acad Emerg Med. 2020;27(11):1106-1115. doi:10.1111/acem.14063

Panchal AR, Satyanarayan A, Bahadir JD, Hays D, Mosier J. Efficacy of Bolus-dose Phenylephrine for Peri-intubation Hypotension. J Emerg Med. 2015;49(4):488-494. doi:10.1016/j.jemermed.2015.04.033

Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multi-center study. Crit Care Med. 2006;34:2355–61.

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

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Podcast 688: tPA Before Thrombectomy Jul 05, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

DEVT Trial, a recent non-inferiority study, looked at giving tPA prior to endovascular thrombectomy and was stopped early because there was no benefit shown to giving tPA before this intervention
Coupled with the SKIP and DIRECT MT trials corroborating these findings, it appears that giving tPA prior to thrombectomy is not indicated
Whether patients should receive tPA prior to transfer for thrombectomy (i.e. they are in a rural healthcare setting) is still unclear

References

Yang P, Treurniet KM, Zhang L, et al. Direct Intra-arterial thrombectomy in order to Revascularize AIS patients with large vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicenter randomized clinical Trial (DIRECT-MT)-Protocol. Int J Stroke. 2020;15(6):689-698. doi:10.1177/1747493019882837

Suzuki K, Matsumaru Y, Takeuchi M, et al. Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial [published correction appears in JAMA. 2021 May 4;325(17):1795]. JAMA. 2021;325(3):244-253. doi:10.1001/jama.2020.23522

Zi W, Qiu Z, Li F, et al. Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke: The DEVT Randomized Clinical Trial. JAMA. 2021;325(3):234-243. doi:10.1001/jama.2020.23523

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

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