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 599: Facial Blocks for the Win Sep 28, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Local anesthetics injected directly into wounds can cause distortion - especially important in facial lacerations
Several blocks can be helpful to help numb branches of the trigeminal nerve (CN V) which innervates the face:
- Supraorbital nerve block: blocks distribution of V1 (most of the forehead) through injection above the eyebrow
- External nasal nerve block: blocks superficial innervation of nose through injection along the nasal dorsum
- Infraorbital nerve block: blocks innervation to lip and cheek by injection below the eye
- Mental nerve block: blocks innervation to chin and lower lip by injection at the mandible
Zygomatic nerve block: blocks innervation to temporal scalp and lateral aspect of forehead by injection at the temple
Greater auricular nerve block: blocks innervation to on and around the lower ear by injection across the sternocleidomastoid

References

http://highlandultrasound.com/facial-blocks

https://www.nysora.com/techniques/head-and-neck-blocks/nerve-blocks-face/

Moskovitz JB, Sabatino F. Regional nerve blocks of the face. Emerg Med Clin North Am. 2013 May;31(2):517-27. doi: 10.1016/j.emc.2013.01.003. Epub 2013 Feb 18. PMID: 23601486.

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

UnfilterED #10: Debi Smith Sep 23, 2020

Show notes

General Counsel attorney, Debi Smith, joins Dr. Nick Tsipis to discuss the ins and outs of healthcare law. Many people forget that a subpoena only compels attendance to a court date, it does not compel one to provide any information on a case without a specific HIPAA compliant authorization for use and disclosure of protected health information. Tune in for more details, perspective on the intricacies of the legal world as it pertains to medicine and for tips on how to navigate different general situations from contracts to litigation.

Time Stamps

0:47 Legal Disclaimer

3:14 Evolution of healthcare law

5:00 Contracts

9:36 Independent medical decision making without influence from a corporation

11:00 Importance of protecting your ideas

12:30 How to navigate litigation

15:09 Choosing to be an expert witness

15:56 Malpractice

17:22 common mistakes with subpoenas

18:56 COVID

22:01 Advice to getting involved in healthcare law

Podcast 598: Sepsis, Round One Sep 22, 2020

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Early antibiotics have been shown to improve outcomes in septic patients time after time
Emerging evidence challenges the concept of one-size-fits-all large fluid boluses for septic shock patients and fluid may worsen patients who have underlying sepsis-induced pulmonary capillary leak
Starting peripheral vasopressors early, and relaxing if fluid resuscitation is successful, is appearing to be a more appropriate strategy than fluids first, then vasopressors

References

CLASSIC Trial Group; Scandinavian Critical Care Trials Group. Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial. Intensive Care Med. 2016 Nov;42(11):1695-1705. doi: 10.1007/s00134-016-4500-7. Epub 2016 Sep 30. PMID: 27686349.

Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. Am J Respir Crit Care Med. 2019 May 1;199(9):1097-1105. doi: 10.1164/rccm.201806-1034OC. PMID: 30704260.

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

Podcast 597: Weather Can be a Headache Sep 21, 2020

Show notes

Contributor: Sam Killian, MD

Educational Pearls:

One study found that patients presented with headaches more frequently when there was high temperatures and low humidity, while higher humidity is correlated to lower incidence of headache. Moon phases had no effect on headache frequency.
A Canadian study looking at over 100,000 ED visits for headaches found increased incidence of headaches when there were higher levels of air pollution/particulates, like smoke.

References

Yilmaz M, Gurger M, Atescelik M, Yildiz M, Gurbuz S. Meteorologic parameters and migraine headache: ED study. Am J Emerg Med. 2015;33(3):409-413. doi:10.1016/j.ajem.2014.12.056

Szyszkowicz M, Stieb DM, Rowe BH. Air pollution and daily ED visits for migraine and headache in Edmonton, Canada. Am J Emerg Med. 2009;27(4):391-396. doi:10.1016/j.ajem.2008.03.013

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

Pediatric Emergencies Brewcast: Pediatric Trauma Sep 16, 2020

Show notes

Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies 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 for traumatic injuries dealt with in the ED and pre-hospital settings.

Dr. Christine Darr, Pediatric Emergency Medicine Physician, discusses a range of traumatic injuries in pediatric patients and how to appropriately perform a physical exam, order radiographic diagnostics to further assess and identify injuries and key steps for management. She reviews growth plate injuries as well as considerations at different developmental stages that can mask the presence of more serious injuries like blunt internal organ trauma without rib fractures and SCIWORA (spinal cord injury without radiographic abnormality). Common injuries associated with abuse at different ages are also addressed to help you identify concerning signs of maltreatment of pediatric patients. Listen for a deep dive into the intricacies of pediatric trauma!

Podcast 596: Peripheral Vasopressors Sep 15, 2020

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Traditional teaching has shied away from using vasopressors through peripheral IVs
Tissue necrosis from extravasation is cited as a risk of use of vasopressors through a peripheral site
However, risk of extravasation is low (2-4%) and even more rarely results in significant complications
Using an IV that is more proximal and larger bore with monitoring can further minimize these risks
Starting with peripheral vasopressors in a critically ill patient appears to be without significant increased cutaneous complications compared to using a central line alone

References

Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015;30(3):653.e9-653.e6.53E17. doi:10.1016/j.jcrc.2015.01.014

Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med. 2015;10(9):581-585. doi:10.1002/jhm.2394

Lewis T, Merchan C, Altshuler D, Papadopoulos J. Safety of the Peripheral Administration of Vasopressor Agents. J Intensive Care Med. 2019;34(1):26-33. doi:10.1177/0885066616686035

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

Podcast 595: Smoking. Still Bad Sep 14, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

On average, smoking reduces life expectancy by 13.2 years for men and for 14.5 years for women
Nicotine is highly addictive and has both stimulant and calming effects
Having a newborn can be a strong motivator to quit so take advantage and educate new (or expecting) parents to the risks of smoking and benefits of quitting
Smoking has been associated with sudden infant death
Biggest predictor of children smoking is seeing their parents smoking
Side effects of smoking that can be discussed with patients are cataracts/blindness, cancers (lung and throat), coronary artery disease, early menopause, osteoporosis/fractures, and impotency

References

Haug S, Schaub MP, Schmid H. Predictors of adolescent smoking cessation and smoking reduction. Patient Educ Couns. 2014;95(3):378-383. doi:10.1016/j.pec.2014.03.004

Mays D, Gilman SE, Rende R, Luta G, Tercyak KP, Niaura RS. Parental smoking exposure and adolescent smoking trajectories. Pediatrics. 2014;133(6):983-991. doi:10.1542/peds.2013-3003

Anderson TM, Lavista Ferres JM, Ren SY, et al. Maternal Smoking Before and During Pregnancy and the Risk of Sudden Unexpected Infant Death. Pediatrics. 2019;143(4):e20183325. doi:10.1542/peds.2018-3325

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

On The Streets #8: Limb Injury and Preservation Sep 09, 2020

Show notes

Dr. Glenda Quan, esteemed Trauma Surgeon at Swedish Medical Center, discusses cases related to limb injury and reviews their management. Topics include proper tourniquet application as well as alternatives to commercially available devices how to manage pain or a difficult patient with significant limb injury. We also explore the use of new "hybrid ORs" where multiple surgical teams can care for various injuries simultaneously and briefly chat about the use of blood products in the prehospital setting. Thought we were done? Nope. We finish with pearls on temperature management as part of trauma resuscitation and find the answer to when you consider reduction of a joint or mid-shaft fracture?

Podcast 594: Topicalization for Awake Intubations Sep 08, 2020

Show notes

Contributor: Ricky Dhaliwal, MD, JD

Educational Pearls:

Topical anesthetization can allow for an awake intubation, which substantially decreases chance of loss of airway or respiratory drive because sedatives/paralytics are not necessary
Lidocaine treatments like URO-JET (2% lidocaine jelly) can be applied through the nare followed by LMX cream (4% lidocaine) which should be applied to the back of the tongue to anesthetize the tongue and larynx.
Good topicalization can be confirmed by testing for lack of a gag reflex

References

Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth Pain Med. 2002;27(2):180-192. doi:10.1053/rapm.2002.30659

Ducharme J, Matheson K. What is the best topical anesthetic for nasogastric insertion? A comparison of lidocaine gel, lidocaine spray, and atomized cocaine. J Emerg Nurs. 2003;29(5):427-430. doi:10.1016/s0099-1767(03)00295-2

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

Podcast 593: TXA for GIB Sep 07, 2020

Show notes

Contributor: Ricky Dhaliwal, MD, JD

Educational Pearls:

Tranexamic acid (TXA) as shown to have mortality benefit to patients with traumatic GI hemorrhage but should it be used to achieve hemostasis in atraumatic GI bleeding?
HALT-IT study looked at TXA for the treatment of upper and lower GI hemorrhage and found no 5 day mortality benefit
Patients given TXA also had higher occurrences of DVT and PE

References

Roberts I, Coats T, Edwards P, et al. HALT-IT--tranexamic acid for the treatment of gastrointestinal bleeding: study protocol for a randomised controlled trial. Trials. 2014;15:450. Published 2014 Nov 19. doi:10.1186/1745-6215-15-450

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

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