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 592: Rapid Antihypertensives Sep 01, 2020

Show notes

Contributor: Ramnik Dhaliwal, MD, JD

Educational Pearls:

Nitrates
- Nitroprusside: becomes effective in under a minute, and becomes ineffective 10 minutes after stopping it.
- - Nitroprusside can metabolize into cyanide leading to toxicity, however this is rare.
- Nitroglycerin: predominately causes vasodilation but some arterial dilation as well; preferred agent in patients with volume overload/CHF
Adrenergic Blocking Agents
- Labetalol: alpha/beta-blocking agent with a rapid onset of 5 minutes or less given as bolus or intravenous drip
- Esmolol: cardioselective beta blocker with rapid onset and short duration of action making it easily titratable
- Hydralazine: direct arterial dilator; patient dependent response that can be unpredictable. Use with caution in patients with CAD or an aortic dissection because there will be a reflexive increase in heart rate to combat the arteriolar dilation.
Calcium Channel Blockers
- Nicardipine: Given as an IV infusion starting at 5g/hr up to 15g/hr. This drug has a slower onset of action making it difficult to titrate and it has a longer serum elimination half-life (3-6 hours)
- Clevidipine: rapid onset and short duration of action; Reduces BP without affecting cardiac filling pressures but can cause reflex tachycardia

References

)Wani-Parekh P, Blanco-Garcia C, Mendez M, Mukherjee D. Guide of Hypertensive Crisis Pharmacotherapy. Cardiovasc Hematol Disord Drug Targets. 2017;17(1):52-57. doi:10.2174/1871529X16666161220142020

Suneja M, Sanders ML. Hypertensive Emergency. Med Clin North Am. 2017;101(3):465-478. doi:10.1016/j.mcna.2016.12.007

Maloberti A, Cassano G, Capsoni N, et al. Therapeutic Approach to Hypertension Urgencies and Emergencies in the Emergency Room. High Blood Press Cardiovasc Prev. 2018;25(2):177-189. doi:10.1007/s40292-018-0261-4

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

Podcast 591: Pediatric Documentation Pearls Aug 31, 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 in the ED and pre-hospital settings. As such, it's important to be careful with the documentation of these patients to maintain accuracy and avoid inclusion of common normal findings that may populate in "normal patient" macros that are inappropriate for pediatric patients.

Dr. Karen Woolf, Pediatric Emergency Medicine Physician, shares some key areas to be wary of in your documentation for pediatric patients. Some examples include the description of vital signs and whether they fall within normal ranges, general appearance descriptors as well as developmental stage specific findings i.e AAOx3, normal gait and fontanelle description etc. Listen for a rundown of the key pointers for keeping pediatric documentation accurate and informative.

Pharmacy Phriday #2: Penicillin and Cephalosporin Allergies Aug 28, 2020

Show notes

The penicillin and cephalosporin drug classes include many first line drug options for infectious disease although high rates of self-reported allergies may cause physicians to seek alternative options. In part two of our dive into antibiotics use for infectious disease, listen as Dr. Rachael Duncan, Emergency Medicine Clinical Pharmacist, addresses the need to investigate the validity of these reported allergies and their severity to avoid us elf riskier alternatives, like fluoroquinolones. Cross-reactivity between cephalosporins is most often dictated by side chain of cephalosporins rather than the beta-lactam ring. Refer to the chart included for cross-reactivity tips.

References:

Li M, Krishna MT, Razaq S, Pillay D. A real-time prospective evaluation of clinical pharmaco-economic impact of diagnostic label of 'penicillin allergy' in a UK teaching hospital. J Clin Pathol 2014; 67(12): 1088-92.
Romano A, Gueant-Rodriguez RM, Viola M, Pettinato R, Gueant JL. Cross-reactivity and tolerability of cephalosporins in patients with immediate hypersensitivity to penicillins. Ann Intern Med 2004; 141(1): 16-22.
Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: A cohort study. J Allergy Clin Immunol 2014; 133(3): 790-6

Mental Health Monthly #4: Trauma, Loss and Grief in First Responders Heightened by COVID-19 Aug 26, 2020

Show notes

Trauma and loss are common issues faced by emergency personnel and first responders. These challenges have since been heightened by the COVID-19 pandemic. On this installment of Mental Health Monthly, Anat 'Nati' Geva, PsyD, LP joins us to discuss the stages of grief in response to loss and trauma and how they pertain to first responders and frontline workers in particular. Each of the five stages of grief: denial, anger, bargaining, despair and acceptance are addressed and explained so you can expand your understanding of the natural process of grieving, identify signs and symptoms and take steps towards moving forward.

If you or a love one is struggling through the grieving process and need more support, we encourage you to utilize the resources below:

My Strengths - https://mystrength.com/ passcode: TMCAProfessional

Responder Strong - https://you.responderstrong.org/

Jason's Foundation - https://jasonfoundation.com/

Rocky Mountain Crisis Partners (also known as "the crisis line") – 1-844-493-8255 (TALK) https://rmcrisispartners.org/

HCAT – 1-844-556-2012

Anat 'Nati' Geva, PsyD, LP

Anat.A.Geva@gmail.com

If you are interested in taking part in a personalized experiential application of the content, there will be a Webex webinar session tomorrow, August 27th from 10 - 11 am MST.

The focus group follow-up is a complimentary experiential component for individuals who want to deepen their understanding of the material from this podcast. It will benefit those who want to take the opportunity to make the content personal to their situation. In this session, participants will discuss the prominent experiences for participants, have more extended time for Q&A, and then explore (a facet of) the primary model used. Time allowing, participants will be invited to join and share insights for the benefit of all participants.

Details for joining:

Join via Webex

Join from a video system or application Dial 1453267047@hcameeting.webex.com Tap to join from a mobile device (attendees only) +1-415-655-0003,,1453267047## United States TOLL

Join by phone +1-415-655-0003 United States TOLL Global call-in numbers

Access code: 145 326 7047 Meeting password: Meeting password: mVx3rt6Kwb

Podcast 590: Esophageal Food Impactions Aug 25, 2020

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Carbonated beverages have shown efficacy in helping patients spontaneously pass esophageal food impactions
Glucagon, while historically used for treatment, has been shown to have significant side effects without any clinical benefit
Definitive treatment is with endoscopy performed typically by a gastroenterologist

References

Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J Emerg Med. 2019;56(5):499-511. doi:10.1016/j.jemermed.2019.01.025

Peksa GD, DeMott JM, Slocum GW, Burkins J, Gottlieb M. Glucagon for Relief of Acute Esophageal Foreign Bodies and Food Impactions: A Systematic Review and Meta-Analysis. Pharmacotherapy. 2019;39(4):463-472. doi:10.1002/phar.2236

Akram J, Amin FM, Toft JG, Rømeling F. Håndtering af fremmedlegeme i øsofagus med synkestop [Treatment of foreign body impactions in oesophagus]. Ugeskr Laeger. 2013;175(10):640-643.

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

Podcast 589: Management of Dental Trauma Aug 24, 2020

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

Dental fractures are described by the Ellis classifications, which are based on the involvement of layers of the teeth:
- Ellis I: involvement of the enamel
- Ellis II: involvement of the enamel and dentin
- Ellis III: involvement of the enamel, dentin, and pulp
While Ellis I injuries can be sent for dental follow up without intervention, Ellis II/III injuries require covering of the exposed dental layers, particularly because bacteria can more easily enter into the pulp
- Calcium hydroxide (Dycal) is used to cover teeth until patients can get to a dentist.
Dental avulsions, or displacement of the tooth from the socket, are time sensitive. Every minute the tooth is not put back in place carries an increased risk of permanent loss. After the tooth is replanted, it requires fixation or bracing
Dental subluxations can also be secured or braced with dental follow up

References

Marte, D, and B Robinson. Dental Trauma. Core EM, 7 Oct. 2019, coreem.net/core/dental-trauma/#ellis-classification-system-for-dental-fractures.

Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011;57(4):375-377.

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

Pharmacy Friday #1: Antibiotic Alternatives to Fluoroquinolones for Infectious Disease Aug 21, 2020

Show notes

Welcome to EMM's first Pharmacy Friday where we dive deeper on a certain pharmacological topic as it pertains to emergency medicine. Dr. Rachael Duncan, emergency medicine clinical Pharmacist, joins us today to talk about antibiotics use for infectious disease, specifically fluoroquinolones. Special thanks to Dr. Nichole Neville, infectious disease pharmacist, for much of the information presented in this podcast.

Educational Pearls:

Levofloxacin and other fluoroquinolones used to be relied upon heavily due to key upsides including ease of use and wide spectrum coverage of common bacteria. Overuse over the past decade has resulted in the discovery of 3 concerns that have led to their use being advised against in most patients These concerns are patient adverse reactions, safety concerns and drug resistance.
Patient adverse reactions include potential QTc prolongation, neurologic symptoms including worsening of myasthenia gravis or peripheral neuropathy and severe hypoglycemia.
Due to these adverse effects, a new term was coined: fluoroquinolone-associated disability. In an FDA report, they looked at the percentage of disability reports among all serious outcome reports of selected antibiotics and found that the top 5 antibiotics that led to disability reports were fluoroquinolones. Safety concerns have led to several black box warnings as well.
Drug resistance due to overuse has also severely decreased the susceptibility rates of fluoroquinolones at many institutions. Check out your facility's antibiograms to get an idea of what susceptibility rates are for different drugs.
Common infections that are inappropriately given fluoroquinolones when other options would be better suited are PNA, UTI and intra-abdominal infections.

Tune in next week for more on cross-reactivity of cephalosporins and penicillins

References:

Fda.gov. 2017. Fluoroquinolone Safety Labeling Changes. [online] Available at: https://www.fda.gov/media/104060/download> [Accessed 21 August 2020].

Idsociety.org. 2018. Practice Guidelines. [online] Available at: https://www.idsociety.org/practice-guideline/practice-guidelines/#/date_na_dt/DESC/0/+/> [Accessed 18 August 2020].

U.S. Food and Drug Administration. 2018. FDA Updates Warnings For Oral And Injectable Fluoroquinolone. [online] Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-updates-warnings-oral-and-injectable-fluoroquinolone-antibiotics> [Accessed 18 August 2020].

Buprenorphine after Naloxone Aug 19, 2020

Show notes

EMM would like to extend a large thank you to the Pain Management and Addiction Medicine section of the American College of Emergency Physicians for allowing us to post their webinar panel discussion facilitated by EMM's own Don Stader, MD, FACEP on Buprenorphine use after Naloxone. This episode discusses the nuances of emergency physicians inducing patients on Buprenorphine following an opioid overdose and covers key considerations including dosing, precipitated withdrawal and contraindications to Buprenorphine administration.

Panelists include:

Rachel Haroz, MD - EM physician boarded in Medical Toxicology and Addiction working in Camden, NJ

Andrew Herring, MD - EM physician boarded in Pain and Addiction working in Oakland, CA and leads California's Bridge program that helps hospitals start Buprenorphine programs

Eric Ketcham, MD, FACEP - EM physician who is a cofounder and chair of ACEP's Pain Management and Addiction Medicine section working in New Mexico

Podcast 588: Esmolol for Refractory Ventricular Fibrillation Aug 18, 2020

Show notes

Contributor: Ricky Dhaliwal, MD, JD

Educational Pearls:

Ventricular Fibrillation (VF) is a potentially fatal cardiac arrhythmia; Refractory VF even more so
Epinephrine stimulates alpha and beta receptors which increase sympathetic tone, thereby increasing cardiac oxygen demand and myocardial calcium levels which can cause new arrhythmias, particularly a problem during resuscitation
Esmolol (or any beta blocker) can be used in VF refractory to defibrillation, epinephrine and amiodarone in a last-ditch effort.
Esmolol in the setting of epinephrine can help prevent some of these known effects from repeated beta stimulation
Dosing esmolol for refractory VF: 500mcg/kg bolus, followed by drip (max typically 1000 mcg/kg/min)
Esmolol is associated with improved mortality in ACLS care in refractory VF

References

Long DA, Long B, April MD. Does β-Blockade for Treatment of Refractory Ventricular Fibrillation or Pulseless Ventricular Tachycardia Improve Outcomes?. Ann Emerg Med. 2020;76(1):42-45. doi:10.1016/j.annemergmed.2020.01.025

Lee YH, Lee KJ, Min YH, et al. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016;107:150-155. doi:10.1016/j.resuscitation.2016.07.243

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

Podcast 587: Puppies Preventing Burnout? Aug 17, 2020

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Burnout happens. This study reminds us to take a few minutes on shift to take care of yourself.
A new study looked at burnout in ER nurses, residents, and attending physicians where they were asked to take a 5-minute break on shift to color or play with a therapy dog.
Researchers measured stress levels and checked salivary cortisol levels after the breaks to see if the therapies were working against a control group who did not have the breaks.
Those who colored reported increased stress levels at the end of their shifts, while those who played with dogs reported decreased stress. Cortisol levels dropped in both coloring and pet therapy groups. Interestingly, patients couldn't see any difference in their providers' stress level.
Those who conducted the study believe maybe coloring increased stress only because those who colored were denied the chance to play with a dog. Go figure.

References

1) Kline JA, VanRyzin K, Davis JC, et al. Randomized Trial of Therapy Dogs Versus Deliberative Coloring (Art Therapy) to Reduce Stress in Emergency Medicine Providers . Acad Emerg Med. 2020; doi:10.1111/acem.13939

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