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 645: Necrotizing Enterocolitis and More Mar 02, 2021

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

Necrotizing Enterocolitis (NEC)
- Presents in the first few days of life (often in the NICU) to 3 weeks old
- Risk factors include prematurity, excess feeding, neonatal sepsis
- Pneumatosis Intestinalisis on abdominal xray caused by bacterial translocation into the bowel wall
- Treated with NG tube, bowel rest and surgical resection
Other causes of pediatric abdominal pain
- Malrotation with volvulus
- - Malrotation is caused by failure of intestinal rotation in the 8th-12th week of development
  - Presents with bilious vomiting, which is a surgical emergency in a neonate
  - 90% of cases present in the first year of life, with most of these presenting in the first month
  - Diagnosed with an upper GI series
- Pyloric Stenosis
- - Typically in males
  - Diagnosed with abdominal ultrasound and treated surgically
- Intussusception
- - Typically presents between 2 months and 2 years with a palpable mass in the RUQ
  - Diagnosed with abdominal ultrasound
- Duodenal atresia
- - Congenital stricture in the duodenum
  - Presents with bilious vomiting and a double-bubble on abdominal xray

References

Alwan R, Drake M, Gurria Juarez J, Emery KH, Shaaban AF, Szabo S, Sobolewski B. A Newborn With Abdominal Pain. Pediatrics. 2017 Nov;140(5):e20164267. doi: 10.1542/peds.2016-4267. PMID: 29042421.

Hostetler MA, Schulman M. Necrotizing enterocolitis presenting in the Emergency Department: case report and review of differential considerations for vomiting in the neonate. J Emerg Med. 2001 Aug;21(2):165-70. doi: 10.1016/s0736-4679(01)00371-7. PMID: 11489407.

Summarized by John Spartz, MS3

Podcast 644: Covid Outcomes Mar 01, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Meta-analysis of 57,420 COVID+ patients evaluated mortality after intubation
- 45% mortality rate for all patients in the study
- 84.4% mortality in patients over 80 years old
POSITIONED Trail assessed need for intubation in patients awake self-proning compared to not
- Risk of intubation and mortality was lower for those self-proning
- 0.3 hazard ratio for intubation in those self-proning

References

Lim ZJ, Subramaniam A, Ponnapa Reddy M, et al. Case Fatality Rates for Patients with COVID-19 Requiring Invasive Mechanical Ventilation. A Meta-analysis. Am J Respir Crit Care Med. 2021;203(1):54-66. doi:10.1164/rccm.202006-2405OC

Jagan N, Morrow LE, Walters RW, Klein LP, Wallen TJ, Chung J, Plambeck RW. The POSITIONED Study: Prone Positioning in Nonventilated Coronavirus Disease 2019 Patients-A Retrospective Analysis. Crit Care Explor. 2020 Oct 1;2(10):e0229. doi: 10.1097/CCE.0000000000000229. PMID: 33063033; PMCID: PMC7531752.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Podcast 643: Convulsions with Gastroenteritis Feb 23, 2021

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Differential Diagnosis: non-accidental trauma, febrile seizure, meningitis, hyponatremia, epilepsy
Convulsions with gastroenteritis is a known entity to cause seizures in infancy
- Predominantly occurs in ages 6 months to 3 years
- Occur with diarrheal episodes
- No electrolyte abnormalities associated with the seizure nor severe dehydration
- Seizures tend to come in clusters
- Most have a normal EEG and do not develop epilepsy
- Reported incidence in gastroenteritis of 1-2% of gastroenteritis
- Treatment addresses the seizures but long term anti-epileptic drugs are typically not needed

References

Kang B, Kwon YS. Benign convulsion with mild gastroenteritis. Korean J Pediatr. 2014;57(7):304-309. doi:10.3345/kjp.2014.57.7.304

Ma X, Luan S, Zhao Y, Lv X, Zhang R. Clinical characteristics and follow-up of benign convulsions with mild gastroenteritis among children. Medicine (Baltimore). 2019;98(2):e14082. doi:10.1097/MD.0000000000014082

Image credit: Kurt Christensen

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Podcast 642: Vasopressors Feb 22, 2021

Show notes

Contributor: Nick Tsipis, MD

Educational Pearls:

Epinephrine: alpha-1, alpha-2, beta-1, and beta 2 agonist - used in cardiac arrest with positive effects on ROSC in prehospital and peri-hopsital setting
Norepinephrine: alpha-1 and beta-1 agonist - used in septic shock to increase cardiac output and peripheral vasoconstriction
Phenylephrine: alpha-1 adrenergic agonist - used in spinal/neurogenic shock as well as medication-induced peri-procedural hypotension (propofol for RSI) as it only helps with vasoconstriction
Dopamine: alpha-1, alpha-2, beta-1, beta 2, and dopamine agonist - used for sepsis in the past, but not recommended due to dysrhythmias
Vasopressin: V1 agonist (vasoconstricts) - used when maxed out of norepinephrine for septic shock
Milrenone: phosphodiesterase inhibitor - used in heart failure to drop preload and afterload
Dobutamine: beta-2 (with minimal beta-1) adrenergic agonist - used in heart failure and cardiogenic shock to reduce afterload

References

Shields SH, Holland RM. Pharmacology of Vasopressors and Inotropes. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. McGraw-Hill; Accessed February 14, 2021.

Episode 31 - Vasopressors. FOAMcast: An Emergency Medicine Podcast. 25 July 2015. https://foamcast.org/tag/vasopressors/

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Podcast 641: Leadless Intracardiac Pacemaker Feb 16, 2021

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Small capsule pacemaker (2.5 cm, 1 ml volume) resides in the heart without any associated wires or leads like a traditional pacemaker
The new version has a 6 year battery life, after which it can be deactivated and a traditional pacemaker put in place
Cost is around 2-4 times that of a traditional pacemaker
NEJM study from 2015 showed it met the primary efficacy endpoint in 90% of patients and the primary safety endpoint in 93.3% of patients
Follow up study showed 3% complication with the intracardiac pacemaker compared to 9% in traditional

References

Groner, Ashley PA-C; Grippe, Kristen PA-C The leadless pacemaker, Journal of the American Academy of Physician Assistants: June 2019 - Volume 32 - Issue 6 - p 48-50 doi: 10.1097/01.JAA.0000554750.85170.d4

Reddy VY, Exner DV, Cantillon DJ, Doshi R, Bunch TJ, Tomassoni GF, Friedman PA, Estes NA 3rd, Ip J, Niazi I, Plunkitt K, Banker R, Porterfield J, Ip JE, Dukkipati SR; LEADLESS II Study Investigators. Percutaneous Implantation of an Entirely Intracardiac Leadless Pacemaker. N Engl J Med. 2015 Sep 17;373(12):1125-35. doi: 10.1056/NEJMoa1507192. Epub 2015 Aug 30. PMID: 26321198.

Chan KH, McGrady M, Wilcox I. A Leadless Intracardiac Transcatheter Pacing System. N Engl J Med. 2016 Jun 30;374(26):2604. doi: 10.1056/NEJMc1604852. PMID: 27355553.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Podcast 640: Kawasaki's Disease Feb 15, 2021

Show notes

Contributor: Peter Bakes , MD

Educational Pearls:

Pediatric Fever + Rash Differential: scarlet fever, measles, rubella, chicken pox, fifth's disease, HHV-6, adenovirus, anaphylaxis, Kawasaki's disease
Kawasaki's is diagnosed clinically with prolonged fever (>7 days fever in 5 days of fever >6 months with 4 of the following:
- Strawberry tongue/fissured lips
- Bilateral conjunctival injection
- Cervical lymphadenopathy
- Hand/foot edema
- Maculopapular rash
Can develop life threatening coronary artery aneurysms
Treated with aspirin/IVIG

References

Modesti AM, Plewa MC. Kawasaki Disease. [Updated 2020 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537163/?report=classic

Ramphul K, Mejias SG. Kawasaki disease: a comprehensive review. Arch Med Sci Atheroscler Dis. 2018;3:e41-e45. Published 2018 Mar 21. doi:10.5114/amsad.2018.74522

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Pharmacy Phriday #9: Xofluza (Baloxavir marboxil) for Influenza Feb 12, 2021

Show notes

Contributor: Rachael Duncan, PharmD BCPS

Educational Pearls:

According to the Department of Public Health and Environment who puts out a weekly report on the influenza virus in Colorado, there appears to be less influenza in Colorado than previous years
A milder influenza outbreak is likely due to mask wearing and social distancing practices
There have only been 22 hospitalizations for influenza in Colorado since the start of the flu season back in September and 0 outbreaks in long-term care facilities
Xofluza (baloxavir marboxil) is an antiviral PA endonuclease inhibitor and was approved by the FDA in 2018 for uncomplicated influenza in patients 12 years and older that have been symptomatic for less than 48 hours
Patient's getting Xofluza must be otherwise healthy or at risk of developing influenza-related complications
Due to limited data, Xofluza would not be a good option for those that are inpatient or critically ill and is best utilized for patients who are being seen in the emergency department and will be sent home
Currently Xofluza is not approved for complicated patients, pregnant patients or those that are breast-feeding which limits its use
When compared with Tamiflu in phase 3 studies, Xofluza was superior to placebo and similar to Tamiflu in shortening the duration of illness
Xofluza is a single dose that is weight based and appears to be very well tolerated with some adverse effects including headache, nausea and diarrhea
Xofluza showed a quicker recovery compared to Tamiflu by 8 hours which could be related to its one-time dosing
Cost is a limiting factor for the use of Xofluza. Tamiflu costs around $25 where as Xofluza (only available as brand name currently) is $156 at the cheapest
Pharmacists are still encouraging everyone to get their influenza vaccines despite less influenza cases this year

References:

Cdphe.colorado.gov. 2021. Influenza (flu) | Department of Public Health & Environment. [online] Available at: [Accessed 11 February 2021].

Ison, M., Portsmouth, S., Yoshida, Y., Shishido, T., Mitchener, M., Tsuchiya, K., Uehara, T. and Hayden, F., 2020. Early treatment with baloxavir marboxil in high-risk adolescent and adult outpatients with uncomplicated influenza (CAPSTONE-2): a randomised, placebo-controlled, phase 3 trial. The Lancet Infectious Diseases, 20(10), pp.1204-1214.

Hayden, F., Sugaya, N., Hirotsu, N., Lee, N., de Jong, M., Hurt, A., Ishida, T., Sekino, H., Yamada, K., Portsmouth, S., Kawaguchi, K., Shishido, T., Arai, M., Tsuchiya, K., Uehara, T. and Watanabe, A., 2018. Baloxavir Marboxil for Uncomplicated Influenza in Adults and Adolescents. New England Journal of Medicine, 379(10), pp.913-923.

Summarized by Emily Mack OMSIII

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.com/cme-courses/ and create an account.

Mental Health Monthly #7: Urine Toxicology in the ED Feb 10, 2021

Show notes

This episode of Mental Health Monthly we will be discussing drugs screens in the Emergency Department with Dr. Justin Romano and Eddie Carillo. Dr. Justin Romano is a current psychiatry resident and Eddie Carillo is a licensed mental health therapist. Check out their podcast Millennial Mental Health Channel on all major podcast platforms. Shout out to Dr. Dave Marshall whose grand round presentation this was based on.

Key Points:

Try not to judge your patient based on the results of their drug screen
Drug screens are used a lot; they are not always accurate
Based on one study there was no significant change in outcome, treatment, disposition or psychiatric course when a drug screen was obtained
Specific good uses for drug screens include new onset of psychiatric symptoms

Educational Pearls:

1 in 8 ED visits are due to psychiatric complaints which is up 44% since mid 2000's
63% of new psychiatric complaints had a medical cause
Physicians use drug screens commonly in the Emergency Department, but often do not understand their limitations and are often not using them in the most clinically effective manner
Urine is by far the most commonly used in the Emergency Department
UA drug screens are notorious for having false positives and false negatives
Length of clearance from the urine:
- Alcohol 12 hours
- Methamphetamines/Amphetamines 48 hours
- Benzodiazepines 3 days
- Opiates 2-3 days
- Cocaine 2-4 days
- Marijuana dependent on use: 3- 15 days
- Phencyclidine (PCP) 8 days
Urine drug screens have a false positive rate of 5-10 % and a false negative rate of 10-15%
False Positive; urine drug screen positive, but drug is not in their body
- False positives for amphetamines: bupropion, trazodone, metformin, promethazine, pseudoephedrine, phentermine and atomoxetine
- False positives for benzodiazepines: sertraline
- False positives for cannabis: ibuprofen, naproxen, proton pump inhibitors
- False positives for opiates: poppy seeds, antibiotics, Benadryl
- False positives for PCP: venlafaxine, ibuprofen and Ambien
- False positives for cocaine: amoxicillin
False Negative; urine drug screen negative, but drug is in the body
- Benzodiazepines: such as alprazolam, clonazepam, lorazepam or triazolam
- Cannabinoids: CBD, synthetic marijuana such as K2
- Opiates: oxycodone, fentanyl, methadone and tramadol
If you get a test that you don't think is accurate you can always send off for a confirmatory test

References

Summarized by Emily Mack OMSIII | Edited by Mason Tuttle

Podcast 639: Rib Fractures in the Elderly Feb 09, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Retrospective review of 5,021 patients over 65 with 2 or more rib fractures recently published
3577 (78 %) were admitted to non-ICU setting
1.1% of these patients had unexpected intubation or ICU transfer
Findings raise questions regarding current guidelines for ICU admission in elderly patients with isolated rib fractures

References

Naar L, El Hechi MW, van Erp IA, Mashbari HNA, Fawley J, Parks JJ, Fagenholz PJ, King DR, Mendoza AE, Velmahos GC, Kaafarani HMA, Saillant NN. Isolated rib cage fractures in the elderly: Do all patients belong to the intensive care unit? A retrospective nationwide analysis. J Trauma Acute Care Surg. 2020 Dec;89(6):1039-1045. doi: 10.1097/TA.0000000000002891. PMID: 32697447.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Podcast 638: Pyogenic Liver Abscess Feb 08, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Pyogenic liver abscesses can be caused by
- Intra-abdominal infection progressing to peritonitis which then drains into liver
- Bacteremia leading to hematogenous spead and seeding
- Local biliary infection with contiguous spread
Patients typically present with signs of sepsis or septic shock and the abscess can be diagnosed using ultrasound or CT
Treat with IV fluids, broad spectrum antibiotics, and consultation for drainage

References

Kurland JE, Brann OS. Pyogenic and amebic liver abscesses. Curr Gastroenterol Rep. 2004 Aug;6(4):273-9. doi: 10.1007/s11894-004-0078-2. PMID: 15245694.

Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: recent trends in etiology and mortality. Clin Infect Dis. 2004 Dec 1;39(11):1654-9. doi: 10.1086/425616. Epub 2004 Nov 9. PMID: 15578367.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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