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 637: LSD Feb 02, 2021

Show notes

Contributor: Katie Sprinkel, MD

Educational Pearls:

Commonly known as "acid," LSD is seeing a resurgence in the population as a recreational hallucination
Onset is about 30 minutes with peak pharmacologic effects at 2-4 hours, the drug's half life is 3 hours resulting in some prolonged effects
While there is not an significant addictive component of LSD, tolerance for LSD does occur and prolonged usage is associated with increased incidence of schizophreniform disorders
Hallucinations and pseudo-hallucinations (sensory misperceptions) are typical of LSD intoxication, other common signs of intoxication include nausea, diaphoresis, tachycardia, mydriasis, and hypertension
More serious effects can be coma, hyperthermia, seizures, cardiac arrest, serotonin syndrome (with concomitant SSRI use) and coagulopathy, although the dose to cause these effects is very high
Treatment is decreasing sensory stimulation, benzodiazepines in some cases, and symptomatic treatment - no specific antidote exists

References

Blaho K, Merigian K, Winbery S, Geraci SA, Smartt C. Clinical pharmacology of lysergic acid diethylamide: case reports and review of the treatment of intoxication. Am J Ther. 1997 May-Jun;4(5-6):211-21. doi: 10.1097/00045391-199705000-00008. PMID: 10423613.

Klock JC, Boerner U, Becker CE. Coma, hyperthermia and bleeding associated with massive LSD overdose. A report of eight cases. West J Med. 1974;120(3):183-188.

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

Podcast 636: May-Thurner Syndrome Feb 01, 2021

Show notes

Contributor: Sam Killian, MD

Educational Pearls:

iliac vein compression syndrome is also called May-Thurner Syndrome
The left leg more frequently develops deep venous thrombosis (DVT) in part because about 1/4 of the population has May-Thurner
May-Thurner syndrome anatomic variant results in a right iliac artery compresses the left iliac vein against the spine, which can promote DVT formation
This is thought to be the cause of 2-3% of DVTs in patients seen in the ED and suspicion for this disease should increased in those with recurrent DVT
Diagnosis is made with MRV/MRA and will typically not be seen on duplex ultrasound
Typical anticoagulation treatment fails to address the underlying structural cause

References

Demir MC, Kucur D, Çakır E, Aksu NM, Onur MR, Sabuncu T, Akkaş M. May-Thurner syndrome: A curious syndrome in the ED. Am J Emerg Med. 2016 Sep;34(9):1920.e1-3. doi: 10.1016/j.ajem.2016.02.045. Epub 2016 Feb 19. PMID: 26971822.

Sharafi S, Farsad K. Variant May-Thurner syndrome: Compression of the left common iliac vein by the ipsilateral internal iliac artery. Radiol Case Rep. 2018;13(2):419-423. Published 2018 Feb 20. doi:10.1016/j.radcr.2018.01.001

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

Pharmacy Phriday #8: Atropine with Ketamine for Conscious Sedation of Pediatrics Jan 29, 2021

Show notes

Educational Pearls:

Atropine has been shown to reduce hypersalivation as well as nausea and vomiting induced by ketamine sedation.
Atropine can increase the occurrence of a transient rash, as well as tachycardia.
There are no guidelines that recommend for or against atropine use in pediatric patients undergoing ketamine induced sedation.
Ultimately, it is the providers decision to include atropine when performing ketamine sedation.
Pediatric dosing for atropine is 0.01mg/kg IM.

References

Heinz P, Geelhoed GC, Wee C, Pascoe EM. Is atropine needed with ketamine sedation? A prospective, randomised, double blind study. Emerg Med J. 2006 Mar;23(3):206-9. doi: 10.1136/emj.2005.028969. PMID: 16498158; PMCID: PMC2464444.
Chong JH, Chew SP, Ang AS. Is prophylactic atropine necessary during ketamine sedation in children? J Paediatr Child Health. 2013 Apr;49(4):309-12. doi: 10.1111/jpc.12149. Epub 2013 Mar 15. PMID: 23495827.
Shi J, Li A, Wei Z, Liu Y, Xing C, Shi H, Ding H, Pan D, Ning G, Feng S. Ketamine versus ketamine pluses atropine for pediatric sedation: A meta-analysis. Am J Emerg Med. 2018 Jul;36(7):1280-1286. doi: 10.1016/j.ajem.2018.04.010. Epub 2018 Apr 5. PMID: 29656945.

Presented and Summarized by Devan Naughton, 4th year pharmacy student | Edited by Ruben Marrero-Vasquez

Podcast 635: Wide Complex Tachycardias Jan 26, 2021

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

Two main differentials for wide complex tachycardia (WCT) include ventricular tachycardia (most common) and supraventricular tachycardia with aberrancy
Brugada syndrome and Wolff-Parkinson White are potential causes
Arrhythmogenic right ventricular dysplasia is a rare congenital cause of WCT that should be considered in younger patients presenting with WCT

References

B Garner J, M Miller J. Wide Complex Tachycardia - Ventricular Tachycardia or Not Ventricular Tachycardia, That Remains the Question. Arrhythm Electrophysiol Rev. 2013;2(1):23-29. doi:10.15420/aer.2013.2.1.23

Katritsis DG, Brugada J. Differential Diagnosis of Wide QRS Tachycardias. Arrhythm Electrophysiol Rev. 2020;9(3):155-160. doi:10.15420/aer.2020.20

Li KHC, Bazoukis G, Liu T, et al. Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) in clinical practice. J Arrhythm. 2017;34(1):11-22. Published 2017 Dec 21. doi:10.1002/joa3.12021

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

Podcast 634: D10 for Hypoglycemia Jan 25, 2021

Show notes

Contributor: Dylan Luyten, MD

Educational Pearls:

D10 may be a better alternative to D50 in correcting hypoglycemia
Risks of D50:
- Can cause extravasation injury
- Risk of rebound hypoglycemia
D10 does not have the same risks and has no significant difference in reversal time of hypoglycemia compared to D50

References

Kiefer MV, Gene Hern H, Alter HJ, Barger JB. Dextrose 10% in the treatment of out-of-hospital hypoglycemia. Prehosp Disaster Med. 2014 Apr;29(2):190-4. doi: 10.1017/S1049023X14000284. Epub 2014 Apr 15. PMID: 24735872.

Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial. Emerg Med J. 2005 Jul;22(7):512-5. doi: 10.1136/emj.2004.020693. PMID: 15983093; PMCID: PMC1726850.

Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account.

Podcast 633: Pathologic Femur Fractures Jan 19, 2021

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Pathologic bone fractures occur due to weakened bones from chronic disease and with less force when compared to non-pathologic fractures
Can be due to bone tumors, bone cysts, infections (osteomyelitis), osteogenesis imperfecta, Paget's disease of bone, and multiple myeloma
Have moth bitten or lytic appearance and you can sometimes see the periosteum peeling away from the bone

References

Angelini A, Trovarelli G, Berizzi A, Pala E, Breda A, Maraldi M, Ruggieri P. Treatment of pathologic fractures of the proximal femur. Injury. 2018 Nov;49 Suppl 3:S77-S83. doi: 10.1016/j.injury.2018.09.044. PMID: 30415673.

Marshall RA, Mandell JC, Weaver MJ, Ferrone M, Sodickson A, Khurana B. Imaging Features and Management of Stress, Atypical, and Pathologic Fractures. Radiographics. 2018 Nov-Dec;38(7):2173-2192. doi: 10.1148/rg.2018180073. PMID: 30422769.

Unbreakable

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Podcast 632: Neonatal Jaundice Jan 18, 2021

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Bilirubin is natural breakdown product of red blood cells but can be neurotoxic if levels become too high
Fetal red blood cells are fragile and break down easier, leading to higher bilirubin levels in neonates
Immature livers and increased intestinal absorption from sterile bowels also contribute to elevated levels and jaundice in all neonates
Other risk factors for neonatal jaundice include: temperature instability, poor feeding, hypoxia at birth, and being of East Asian descent
Neonatal bilirubin levels are referenced to time since birth using a nomogram to determine the need for light therapy (or exchange transfusion)

References

Mitra S, Rennie J. Neonatal jaundice: aetiology, diagnosis and treatment. Br J Hosp Med (Lond). 2017 Dec 2;78(12):699-704. doi: 10.12968/hmed.2017.78.12.699. PMID: 29240507.

Woodgate P, Jardine LA. Neonatal jaundice: phototherapy. BMJ Clin Evid. 2015 May 22;2015:0319. PMID: 25998618; PMCID: PMC4440981.

Colletti JE, Kothari S, Jackson DM, Kilgore KP, Barringer K. An emergency medicine approach to neonatal hyperbilirubinemia. Emerg Med Clin North Am. 2007 Nov;25(4):1117-35, vii. doi: 10.1016/j.emc.2007.07.007. Erratum in: Emerg Med Clin North Am. 2008 Feb;26(1):xi. Kothori, Samip [corrected to Kothari, Samip]. PMID: 17950138.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Pharmacy Phriday #7: Bactrim Adverse Events Jan 15, 2021

Show notes

Contributor: Cheyenne Bean, PharmD

Educational Pearls:

Bactrim (TMP-SMX) is a sulfa antibiotic used for a number of infections but can have untoward effects.
Hypoglycemia can be induced by the sulfa component of Bactrim, which binds receptors in the pancreas causing insulin to be secreted, dropping blood sugar levels.
- Oral diabetic medications, specifically sulfonylureas, when taken with Bactrim most often lead to these hypoglycemic episodes.
Hyperkalemia can be induced by Trimethoprim by blocking potassium excretion in the kidney, so Bactrim in combination with ACE inhibitors/ARBs/spironolactone can induce high potassium.
When prescribing Bactrim, remember to check home medications and if a patient is taking an above medication, check a baseline BGL and potassium.

References

1) Khorvash F, Moeinzadeh F, Saffaei A, Hakamifard A. Trimethoprim-sulfamethoxazole Induced Hyponatremia and Hyperkalemia, The Necessity of Electrolyte Follow-up in Every Patient. Iran J Kidney Dis. 2019 Jul;13(4):277-280. PMID: 31422395.

2) Kennedy KE, Teng C, Patek TM, Frei CR. Hypoglycemia Associated with Antibiotics Alone and in Combination with Sulfonylureas and Meglitinides: An Epidemiologic Surveillance Study of the FDA Adverse Event Reporting System (FAERS). Drug Saf. 2020 Apr;43(4):363-369. doi: 10.1007/s40264-019-00901-7. PMID: 31863282; PMCID: PMC7117991.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Podcast 631: UK COVID-19 Mutation Jan 13, 2021

Show notes

Contributor: Gretchen Hinson, MD

Educational Pearls:

Viruses mutate frequently and a new variant of COVID has been found in the United Kingdom.
Mutations typically occur due to transcription errors during virus replication leading to slight changes in the virus which can alter its virulence, and this UK mutation has shown more infectivity.
The UK variant was first identified on 9/20/20 and sequenced in October
The variant has a mutation of the spike protein with increased receptor binding capacity, making it more efficient at infecting cells
Children seem to be more susceptible to this variant as compared to the prior COVID strains.

References

1) Tang JW, Tambyah PA, Hui DS. Emergence of a new SARS-CoV-2 variant in the UK. J Infect. 2020 Dec 28:S0163-4453(20)30786-6. doi: 10.1016/j.jinf.2020.12.024. Epub ahead of print. PMID: 33383088.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Podcast 630: Evolution of an STEMI Jan 12, 2021

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

Hyperacute T waves can occur immediately and typical last less than an hour
- Hyperacute T waves are typically broader than peaked T-waves, which are associated with hyperkalemia
ST elevation which usually starts within an hour of the inciting event and can last up to a few days, and often follows the hyperacute T-waves
Q waves can begin at the time ST elevation begins and can remain permanently
T waves can invert before normalizing again days later

References

Levis JT. ECG Diagnosis: Hyperacute T Waves. Perm J. 2015;19(3):79. doi:10.7812/TPP/14-243

Vogel B, Claessen BE, Arnold SV, Chan D, Cohen DJ, Giannitsis E, Gibson CM, Goto S, Katus HA, Kerneis M, Kimura T, Kunadian V, Pinto DS, Shiomi H, Spertus JA, Steg PG, Mehran R. ST-segment elevation myocardial infarction. Nat Rev Dis Primers. 2019 Jun 6;5(1):39. doi: 10.1038/s41572-019-0090-3. PMID: 31171787.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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