Emergency Medical Minute

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Pediatric Emergencies Brewcast: Common Respiratory Conditions in Pediatric Patients Oct 21, 2020

Show notes

Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies geared towards mid-level providers at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true when dealing with respiratory illnesses across different age ranges.

Dr. Parisa Jamshidi, Pediatric Emergency Physician, reviews common respiratory illnesses including bronchiolitis, croup and bacterial tracheitis in pediatric patients covering their presentation on exam and via diagnostics, treatment plans and special considerations. Her lecture is complete with a case review of a patient presenting with croup and its management, differentiation of airway sounds and high flow oxygen delivery recommendations. Listen to brush up on on your knowledge of pediatric respiratory emergencies.

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.

Photo by National Cancer Institute on Unsplash

Podcast 606: The Oxygen Wars Oct 20, 2020

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

The use of oxygen is controversial when treating patients with certain conditions, like MI's, stokes, or ARDS because adverse outcomes have been demonstrated with using high oxygen concentrations.
The Oxygen ICU trial looked at using higher and lower oxygen levels in treating intubated ARDS patients and found that mortality was improved when less oxygen was given allowing oxygen saturations to sit around 95% versus using high oxygen levels to obtain 100% blood oxygen saturation.
The LOCO trial tested using even lower oxygen concentrations allowing patients to have oxygen saturations around 88% compared to more oxygen with saturation goals of 96%. They found a 15% increase in mortality in the lower saturation group and had some incidences of mesenteric ischemia leading to a premature termination of the trial due to the detrimental outcomes.
This means a blood oxygen saturation rate of around 94% is probably a safe bet for patients to reduce episodes of hypoxia but limit over oxygenation injuries, especially in patients requiring longer term oxygen therapy.

References

1) Girardis M, Busani S, Damiani E, Donati A, Rinaldi L, Marudi A, Morelli A, Antonelli M, Singer M. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA. 2016 Oct 18;316(15):1583-1589. doi: 10.1001/jama.2016.11993. PMID: 27706466.

2) Barrot L, Asfar P, Mauny F, Winiszewski H, Montini F, Badie J, Quenot JP, Pili-Floury S, Bouhemad B, Louis G, Souweine B, Collange O, Pottecher J, Levy B, Puyraveau M, Vettoretti L, Constantin JM, Capellier G; LOCO2 Investigators and REVA Research Network. Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome. N Engl J Med. 2020 Mar 12;382(11):999-1008. doi: 10.1056/NEJMoa1916431. PMID: 32160661.

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

Podcast 605: Acute Limb Ischemia Oct 19, 2020

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

Classically presents with the 6Ps: Pain, pallor, paresthesia, pulseless, poikilothermia (cold), and paralysis
Acute limb ischemia occurs by embolic or thrombotic causes
Thrombotic causes are now more common due to aging populations and advancements in vascular surgery like stents which can be a nidus for thrombosis.
Sudden onset of pain without prior symptoms is more typical of embolic causes
Preceding symptoms leading to acute ischemia are more often from thrombosis
Diagnosis can be clinical based on absent pulses, ultrasound or CT angiogram
Definitive treatment includes thrombectomy, stenting, or bypass surgery to restore the blood flow to the distal limb

References

McNally MM, Univers J. Acute Limb Ischemia. Surg Clin North Am. 2018 Oct;98(5):1081-1096. doi: 10.1016/j.suc.2018.05.002. PMID: 30243449.

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

On the Streets #9: Advanced Applications of Capnography Oct 14, 2020

Show notes

Capnography is the measurement of the partial pressure of exhaled CO2 and is an indirect measurement of your cellular respiration. It is displayed visually as a block-like waveform during the exhalation phase of respiration and monitors ventilation in real-time. Capnography is the gold standard for monitoring sedated and intubated patients in the hospital and the field and can be used in many other situations to discern more information about your patient.

Our host Jordan Ourada is joined by Dr. Eric Hill who is a board certified Emergency Physician, EMS Director for 9 agencies around Colorado, a retired military physician with the Army, former paramedic firefighter and combat veteran to discuss advanced applications of capnography to monitor a range of different patients in the pre-hospital setting. Tune in to learn how to apply capnography to monitor your patients and detect serious conditions like sepsis and DKA and initiate time-sensitive interventions that reduce mortality in patients.

Quick Educational Pearls:

Normal range is between 35 - 45 mmHg
Low capnography indicates they are blowing off CO2
High capnography indicates they are retaining CO2
Normal waveform morphology is box-like with gradual expiratory plateau after expiratory upstroke
Monitor your patient's status and interpret the capnography numbers, rate and waveforms accordingly

Time Stamps

1:32 Capnography definition

6:36 Normal range

7:40 Reading capnography waveforms

12:36 Capnography monitoring in sedated/intubated patients

13:36 Intubation monitoring

18:03 VQ match vs mismatch

21:42 Asthmatic patients

24:30 Capnography cannula

26:24 Cardiac arrest uses

31:28 Acid-base physiology

37:28 Diabetic patients

40:15 COPD patients

41:42 CHF patients

45:18 Head injury patients

52:07 Sepsis detection and subsequent prehospital management

1:08:15 Closing thoughts on using capnography in the field

REFERENCES

Brandt, P. "Current Capnography Field Uses." JEMS. 2010, Nov.
DiCorpo,P.,etal."CapnographyProvidesBiggerPhysiological

Picture to Maximize Patient Care." JEMS. 2015, Nov.
Eckstein,M.,etal."End-tidalCO2asapredictorofsurvivalinout-of- hospital cardiac arrest." Prehosp Disaster Med. 2011 Jun;26(3):148-50
Kodali,B."Physicsofcapnography."2014
Poste,J.,etal."Airmedicaltransportofseverelyhead-injured patients undergoing paramedic rapid sequence intubation." Air Med J. 2004 Jul-Aug;23(4):36-40

Davis, D., et al. "Predictors of Intubation Success and Therapeutic Value of Paramedic Airway Management in a Large, Urban EMS System." Prehospital Emergency Care. 2006: Vol. 10, Iss. 3.
Grmec, S. "Comparison of three different methods to confirm endotracheal tube placement in emergency intubation." Intensive Care Medicine. 2002; 28: 701-4.
Silvestri, et al. "The Effectiveness of out of hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system." Ann Emerg Med. 2005; 45: 497- 503.
Hartman, et al. "Systematic Review and Meta- Analysis of End-Tidal Carbon Dioxide Values Associated With Return of Spontaneous Circulation During Cardiopulmonary Resuscitation." Journal Intensive Care Med. 2015, Oct;30 (7) 426-35.

Levine, et al. "End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest." N England J Med. 1997, Jul 31; 337(5): 301-6.
AHA 2015 Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Hunter CL, et al. "A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis." American Journal of Emergency Medicine. 2016 May; 34(5):813-819.
Bou Chebi, R, et al. "Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department." BMC Emerg Med. 2016 Jan 29; 16:7
Soleimanpour, H, et al. "Predictive value of capnography for suspected diabetic ketoacidosis in the emergency department." West J Emerg Med. 2013;14(6): 590-4.

Podcast 604: Baclofen Withdrawal Oct 13, 2020

Show notes

Contributor: Erik Verzemnieks, MD

Educational Pearls:

Baclofen is used to treat muscle spasms or spasticity.
Baclofen comes in two forms: oral and intrathecal
Withdrawal is much more common with those receiving intrathecal administration from a Baclofen pump, which is typically spinal cord patients
Withdrawal symptoms usually start within 1-3 days after stopping baclofen
Symptoms include altered mental status, muscle rigidity, and fevers, which can mimic other severe illnesses
It is nearly impossible to reverse withdrawal symptoms with oral baclofen if a patient is receiving it intrathecally, so solving the pump problem is key

References

Ross JC, Cook AM, Stewart GL, Fahy BG. Acute intrathecal baclofen withdrawal: a brief review of treatment options. Neurocrit Care. 2011 Feb;14(1):103-8. doi: 10.1007/s12028-010-9422-6. PMID: 20717751.

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

Podcast 603: Don't Sedate. Block. Oct 12, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Fractures and dislocations that require reduction do not necessarily require sedation
Nerve blocks are an effective alternative that can provide analgesia to reduce fractures and dislocations and provide sustained pain relief after the reduction is completed
Hematoma blocks are effective for distal radius and various ankle fractures
Shoulder dislocations can be reduced by performing a scapular nerve block

References

Tezel O, Kaldirim U, Bilgic S, Deniz S, Eyi YE, Ozyurek S, Durusu M, Tezel N. A comparison of suprascapular nerve block and procedural sedation analgesia in shoulder dislocation reduction. Am J Emerg Med. 2014 Jun;32(6):549-52. doi: 10.1016/j.ajem.2014.02.014. Epub 2014 Feb 17. PMID: 24721024.

Tseng PT, Leu TH, Chen YW, Chen YP. Hematoma block or procedural sedation and analgesia, which is the most effective method of anesthesia in reduction of displaced distal radius fracture? J Orthop Surg Res. 2018 Mar 27;13(1):62. doi: 10.1186/s13018-018-0772-7. PMID: 29580286; PMCID: PMC5869786.

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

Podcast 602: Post-Narcan Observation Oct 06, 2020

Show notes

Contributor: Donald Stader, MD

Educational Pearls:

Not uncommon for patients presenting after opiate overdose and narcan administration to be observed for 4-6 hours
This has been based more on tradition than evidence
Observation periods for overdose may vary based on the opiate(s) used
Fentanyl and heroin have half lives of about 2 hours, while oxycodone and methadone have significantly longer half lives.
HOUR trial attempted to externally validate a scoring tool for stratification of low risk patients appropriate for discharge after 1 hour

References

Clemency BM, Eggleston W, Shaw EW, Cheung M, Pokoj NS, Manka MA, Giordano DJ, Serafin L, Yu H, Lindstrom HA, Hostler D. Hospital Observation Upon Reversal (HOUR) With Naloxone: A Prospective Clinical Prediction Rule Validation Study. Acad Emerg Med. 2019 Jan;26(1):7-15. doi: 10.1111/acem.13567. Epub 2018 Dec 28. PMID: 30592101.

Summarized by Will Dewispelaere, MD | Edited by Erik Verzemnieks, MD

Podcast 601: Droperidol Oct 05, 2020

Show notes

Contributor: Sam Killian, MD

Educational Pearls:

Droperidol (Inapsine) is an antipsychotic drug with efficacy for nausea, vomiting, headaches, and treating agitation
In the early 2000's, Droperidol received a black box warning for QT prolongation
This caused a precipitous drop of in administration and ultimately led to a stop in production
More careful analysis since has called into question the true incidence of QT prolongation in typical dosing
Retrospective review published this year looked at 15,374 non-critical and 1,172 critical patients who received droperidol with only a single episode of Torsades des pointes (which was attributed to multiple other risk factors)
Of the 2,431 non-critical patients, and 396 critical patients, who received an ECG before and after administration, there were no changes to the mean QTc
Droperidol is being manufactured again and the prior black box warning being called into question, so it will likely begin to become more widely available for use

References

Cole JB, Lee SC, Martel ML, Smith SW, Biros MH, Miner JR. The Incidence of QT Prolongation and Torsades des Pointes in Patients Receiving Droperidol in an Urban Emergency Department. West J Emerg Med. 2020 Jul 2;21(4):728-736. doi: 10.5811/westjem.2020.4.47036. PMID: 32726229; PMCID: PMC7390553.

Perkins J, Ho JD, Vilke GM, DeMers G. American Academy of Emergency Medicine Position Statement: Safety of Droperidol Use in the Emergency Department. J Emerg Med. 2015 Jul;49(1):91-7. doi: 10.1016/j.jemermed.2014.12.024. Epub 2015 Mar 30. PMID: 25837231.

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

Pediatric Emergencies Brewcast: Pediatric Fever Sep 30, 2020

Show notes

Dr. Leslie Tourangeau, Pediatric Emergency Medicine Physician, breaks down what qualifies as a fever and how they should be managed for different development ranges of pediatric patients. It's important to consider the timeline of the patient's fever and the patient's vaccination history to inform your differential diagnoses and guide your workup. Tune in for a full run-down on how to proceed with pediatric fever patients you may encounter in the Emergency Department, complete with workup, consultation and disposition recommendations.

References: Up To Date

Podcast 600: Penicillin Allergy? Sep 29, 2020

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

True allergies to penicillin compared to reported allergies from patients ranges around 10%
Recent study took patients undergoing sensitivity tests and developed the PEN(icillin)-FAST score to address reported penicillin allergies
PEN-FAST has four components for a total score of 0-4:

o F = five years or less since prior reaction.

o A = Angioedema/Anaphylaxis.

o S = Severe cutaneous reaction (rash).

o T = Treatment, did they require treatment for a reaction?

Patients with a score of 0 had
Even a score of 1-2 points had around 5% incidence of a true allergy

References

Trubiano JA, Vogrin S, Chua KYL, Bourke J, Yun J, Douglas A, Stone CA, Yu R, Groenendijk L, Holmes NE, Phillips EJ. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med. 2020 May 1;180(5):745-752. doi: 10.1001/jamainternmed.2020.0403. PMID: 32176248; PMCID: PMC7076536.

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

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