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 629: Inferior STEMI Jan 11, 2021

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

EKGs look at different angles, or vectors, of the heart's electrical conduction as it travels through the heart. Knowing how to read these vectors is essential in diagnosing locations of cardiac pathologies
Leads II, III, and aVF follow an inferior path, so ST elevation in those leads indicates inferior involvement
Major complications more common with inferior STEMIs can include:
- hypotension which can be made worse by nitroglycerin
- Severe bradycardia due to SA/AV node involvement
Inferior STEMI, barring no hypotension or bradycardia, have better mortality than other types

References

Warner MJ, Tivakaran VS. Inferior Myocardial Infarction. 2020 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 29262146.

Summarized by Jackson Roos, 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.com/cme-courses/ and create an account.

Podcast 628: ST Elevation Jan 05, 2021

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

STEMI criteria is not just 1mm elevation in contiguous leads
- 1.5 mm in V2-V3 for women
- 2.0 mm in V2-V3 for men
- 2.5 mm in V2-V3 for men under 40
Inferior MI typically have ST elevation in leads II, III and aVF
- Usually inferior MI's show reciprocal changes (ST depression) in the lateral leads.
Lateral MI typically elevation in V5, V6, I, and aVL
Anterior MI show elevation in leads V1-4
Right sided MIs have mixed pattern, showing elevation in V1-V2 and V4 along with the inferior leads.
Right sided MI's are very sensitive to nitrates, especially if they become intubated because this combination can drop pre-load significantly leading to profound hypotension

References

Akbar H, Foth C, Kahloon RA, et al. Acute ST Elevation Myocardial Infarction. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532281/

Namana V, Gupta SS, Abbasi AA, Raheja H, Shani J, Hollander G. Right ventricular infarction. Cardiovasc Revasc Med. 2018 Jan;19(1 Pt A):43-50. doi: 10.1016/j.carrev.2017.07.009. Epub 2017 Jul 14. PMID: 28822687.

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

Podcast 627: Oxygen Like It's Hot Jan 04, 2021

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

High flow nasal cannula (HFNC) has become more utilized with COVID pandemic
Multiple studies have shown this method improves both oxygenation and ventilation
Newer studies have shown the respiratory benefit of HFNC vs normal oxygen in patients suffering from CHF and those with do not intubate orders who are experiencing respiratory distress.
Heated high flow is another option to provide ventilator and oxygen support to patients who either do not need or do not want to be intubated

References

Kang MG, Kim K, Ju S, et al. Clinical efficacy of high-flow oxygen therapy through nasal cannula in patients with acute heart failure . J Thorac Dis. 2019;11(2):410-417. doi:10.21037/jtd.2019.01.51

Peters SG, Holets SR, Gay PC. High-flow nasal cannula therapy in do-not-intubate patients with hypoxemic respiratory distress. Respir Care. 2013 Apr;58(4):597-600. doi: 10.4187/respcare.01887. PMID: 22781059.

Sharma S, Danckers M, Sanghavi D, et al. High Flow Nasal Cannula. [Updated 2020 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526071/

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

Pharmacy Phriday #6: Tik Tok Benadryl Challenge and Diphenhydramine Toxicity Jan 01, 2021

Show notes

Contributor: Ruben Marrero-Vasquez, PharmD

Educational Pearls:

ACEP and FDA have both issued warnings about the viral Tik Tok Benadryl (diphenhydramine) challenge where individuals voluntarily overdose on diphenhydramine which can cause fatal toxicity
Diphenhydramine is typically dosed at 0.5-1 mg/kg in pediatric patients Q4-6 PRN and carries a fatal dose of 20-40 mg/kg but anywhere from 3-5x recommended dose does can cause toxicity
Diphenhydramine toxicity causes both central and peripheral anticholinergic toxicity
- Central anticholinergic toxicity symptoms: delirium, agitation, combativeness, confusion, restlessness, hallucinations, ataxia, tremor and seizures
- Peripheral anticholinergic toxicity symptoms: tachycardia, dry flushed skin, dry mucus membranes, thick secretions, dilation of pupils, urinary retention, and decreased bowel sounds
Pneumatic to help you remember anticholinergic toxidrome:
- Red as a beet
- Dry as a bone
- Blind as a bat
- Mad as a hatter
- Hot as a hare
- Full as a flask
Management typically only requires supportive care, agitation from central anticholinergic delirium can be hardest aspect to treat, IV benzodiapines are first line treatment to control and may require large doses to prevent rhabdomyolysis and hyperthermia
Diphenhydramine toxicity has been associated with blockade of sodium and potentially potassium channels increasing risk of arrhythmia and seizures. Cardiac changes can include: QRS widening, myocardial depression, QT prolongation and torasades-type ventricular tachycardia.
- Wide QRS complexes indicate delayed ventricular depolarization caused by sodium channel blockade, bolus of sodium bicarbonate can be used dosed 1-2 mEq/kg followed by continuous infusion
- Prolonged QT: restoration of low serum potassium and magnesium to high normal range
Benzodiazipines should be used as first line therapy for toxin induced seizures
- Don't use fosphenytoin or phenytoin sodium channel blockers as they can worsen cardiac conduction

References

Olson KR, Anderson IB, Benowitz NL, Blanc PD, Clark RF, Kearney TE, Kim-Katz SY, Wu AH. Diphenhydramine. In: Poisoning & Drug Overdose. 7th ed.McGraw Hll; 2018: 544-545.
FDA Warns About Serious Problems With High Doses Of The Allergy Medicine Diphenhydramine (Benadryl).(09/24/2020). CDC website. Accessed December 01, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-serious-problems-high-doses-allergy-medicine-diphenhydramine-benadryl.
Su M, Goldman M. Anticholinergic Poisoning. UpToDate. https://www.uptodate.com/contents/anticholinergic-poisoning?search=diphenhydramine overdose&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Published October 6, 2020. Accessed December 26, 2020.

Summarized by Mason Tuttle

Mental Health Monthly #6: Suicide Assessment Dec 30, 2020

Show notes

EMM is excited to welcome back the hosts of Millennial Mental Health Channel podcast to explain the key points of a robust suicide assessment in the ED. Dr. Justin Romano is a third year psychiatry resident in Omaha, Nebraska and Eddie Carrillo is a licensed mental health therapist currently working at partial hospitalization and IOP eating disorder program in Portland, Oregon. Their podcast Millennial Mental Health Channel seeks to explore the world of mental health from their two professional perspectives.

You can listen to their podcast on all major streaming platforms including Apple Podcasts, Spotify and Google Podcasts.

Follow them on Twitter and Instagram @millennialmhc

Contributors: Dr. Justin Romano and Eddie Carrillo, M.A., LPC

Educational Pearls:

Suicide is 10th most common cause in U.S. and the rate rose by 30% from 2000-2016 and the CDC reports that there was a 25% increase in ED visits for SI from January 2017 - December 2018
Use an objective screening tool like Columbia-Suicide Severity Rating Scale (C-SSRS) when assessing patients as they can help detect SI although ultimately it is up to your clinical impression to make a decision
Suicide reduction measures and strategies work! Take advantage of social workers when setting up outpatient resources for patients i.e. gun locks
Risk Factors include: prior attempts, substance use/abuse, mental disorders (especially depression and bipolar disorder), access to lethal means (most modifiable by risk reduction strategies), knowing someone who has died by suicide, social isolation, chronic disease or disability, lack of access to mental health resources, recent changes in social status and being a member of a high risk demographic (older caucasian men, LGBTQ+, Native Americans and Alaskan Natives)
Protective Factors include: good followup as an outpatient, good social support, life skills, purpose in life, cultural beliefs, children and sense of responsibility in the family
Sober up and reassess suicidality
If not medically cleared, admit to hospital to address these complaints and then address suicidality
If they have suicidal thoughts, plan and are reaching out for help because they don't want to do it then send to inpatient facility
Consult psychiatry to explain inpatient psych or when you're worried about patient safety to have them weigh in
Get collateral by talking to a family member to verify that the patient is telling the truth
At the end of the day, thorough documentation of risk and protective factors and results of screening tool in Assessment and Plan is essential to protecting yourself as a professional

References

Betz ME, Boudreaux ED. Managing Suicidal Patients in the Emergency Department. Ann Emerg Med. 2016;67(2):276-282. doi:10.1016/j.annemergmed.2015.09.001

Suicide. National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/suicide.shtml. Published September 2020. Accessed December 30, 2020.

Zwald ML, Holland KM, Annor FB, et al. Syndromic Surveillance of Suicidal Ideation and Self-Directed Violence — United States, January 2017–December 2018. MMWR Morb Mortal Wkly Rep 2020;69:103–108. DOI: http://dx.doi.org/10.15585/mmwr.mm6904a3 .

Summarized by Mason Tuttle

Podcast 626: Updated Gonorrhea Treatment Dec 29, 2020

Show notes

Educational Pearls:

The CDC has made new formal recommendations for treating Gonorrhea due to increasing resistance to Rocephin and Azithromycin.
New recommendations:
- Confirmed gonorrhea: Ceftriaxone 500 mg once
- Empiric treatment: Ceftriaxone 500 mg once followed by 7 days Doxycycline 100 mg BID
- No longer using Azithromycin due to high resistance
Second line:
- Gentamycin IM
- Cefixime 800 mg oral
Pharyngeal involvement has high resistance rates to second line agents and ceftriaxone is strongly preferred

References

St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6.

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

Podcast 625: High Altitude Cerebral Edema (HACE) Dec 28, 2020

Show notes

Contributor: Tom Seibert, MD

Educational Pearls:

High altitude cerebral edema (HACE) is the end stage of acute mountain sickness and is diagnosed when patients develop neurologic dysfunction, ataxia, and altered mental status.
The pathophysiology of HACE is thought to be due to increased cerebral blood flow and increased capillary permeability causing vasogenic edema and brain swelling
HACE is linked to extreme altitude
Rapid descent should be done as soon as possible for this potentially fatal condition
Oxygen can be supportive
Dexamethasone is also typically indicated (8mg initially followed by 4 mg every 6 hours)

Editor's note: HACE can occur at altitudes as low as 8000 feet so don't automatically assume it can't/doesn't happen in the US

References

Jensen JD, Vincent AL. High Altitude Cerebral Edema. 2020 Aug 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 28613666.

Hackett PH, Yarnell PR, Weiland DA, Reynard KB. Acute and Evolving MRI of High-Altitude Cerebral Edema: Microbleeds, Edema, and Pathophysiology. AJNR Am J Neuroradiol. 2019 Mar;40(3):464-469. doi: 10.3174/ajnr.A5897. Epub 2019 Jan 24. PMID: 30679208; PMCID: PMC7028681.

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

Podcast 624: Timing and Tips on Sepsis Dec 22, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Time can be an important factor in outcomes regarding sepsis including mortality
Emphasis has grown on early administration of antibiotics and IV fluids in sepsis
However, early initiation of vasopressors for hypotensive patients may have significant mortality benefit as well

References

Hayden GE, Tuuri RE, Scott R, et al. Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED. Am J Emerg Med. 2016;34(1):1-9. doi:10.1016/j.ajem.2015.08.039

Colling KP, Banton KL, Beilman GJ. Vasopressors in Sepsis. Surg Infect (Larchmt). 2018;19(2):202-207. doi:10.1089/sur.2017.255

Colon Hidalgo D, Patel J, Masic D, Park D, Rech MA. Delayed vasopressor initiation is associated with increased mortality in patients with septic shock. J Crit Care. 2020 Feb;55:145-148. doi: 10.1016/j.jcrc.2019.11.004. Epub 2019 Nov 9. PMID: 31731173.

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

Podcast 623: Acute Mountain Sickness Dec 21, 2020

Show notes

Contributor: Tom Seibert, MD

Educational Pearls:

Acute Mountain sickness (AMS) can cause headache along with fatigue, nausea, vomiting, insomnia
Typically occurs above 6500 feet (not 65,000) in elevation
Acclimation to altitude can help prevent symptoms
if not treated, AMS can advance to severe illness involving cerebral or pulmonary edema.
Mild symptoms can be managed with rest but more severe symptoms will require descent, oxygen, acetazolamide and steroids
Acetazolamide can be used as both a preventative and therapeutic drug

References

Davis C, Hackett P. Advances in the Prevention and Treatment of High Altitude Illness. Emerg Med Clin North Am. 2017 May;35(2):241-260. doi: 10.1016/j.emc.2017.01.002. PMID: 28411926.

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

Podcast 622: High Altitude Pulmonary Edema (HAPE) Dec 15, 2020

Show notes

Contributor: Thomas Seibert, MD

Educational Pearls:

High Altitude Pulmonary Edema (HAPE) typically occurs 2-4 days after arriving at elevation
Symptoms include:
- Fatigue
- Dyspnea
- Cough
Treatment includes:
- Descent to lower elevation
- Oxygen supplementation
- Nifedipine
Caused by sympathetic stimulation from hypobaric hypoxic exposure, causing uneven pulmonary vasculature constriction and when paired with a leaky endothelium, pulmonary edema. #science

References

Swenson ER, Bärtsch P. High-altitude pulmonary edema. Compr Physiol. 2012 Oct;2(4):2753-73. doi: 10.1002/cphy.c100029. PMID: 23720264.

Johnson NJ, Luks AM. High-Altitude Medicine. Med Clin North Am. 2016 Mar;100(2):357-69. doi: 10.1016/j.mcna.2015.09.002. PMID: 26900119.

Hultgren HN. High-altitude pulmonary edema: current concepts. Annu Rev Med. 1996;47:267-84. doi: 10.1146/annurev.med.47.1.267. PMID: 8712781.

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

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