Emergency Medical Minute

Latest Episodes:

On the Streets #7: Burns in the Pre-Hospital and ED Setting Aug 12, 2020

Show notes

Burns are low-volume, high-acuity injuries that require special attention and care from the pre-hospital team to the Emergency Department and finally to a dedicated burn unit and ICU. As a first responder in the pre-hospital setting, there are a couple things that need to remain at the forefront of your mind when dealing with burn patients.

On this episode of On the Streets, host Jordan Ourada sits down with Board Certified Plastic Surgeon and Hand Surgeon Dr. Benson Pulikkottil, who is the Medical Director for Swedish Medical Center's Burn Unit and Sean McConnell RN, former flight nurse and current charge nurse at Swedish's burn clinic to review the most important pearls to pre-hospital practice when it comes to burns. They discuss the in-depth importance of the details surrounding the mechanism of injury, field treatments and surface area estimation among many other nuances related to burn care. Tune in to hear from the experts about how to provide the best possible care for your burn patients when they present themselves.

Podcast 586: Toxic Shock Syndrome Aug 11, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Toxic shock syndrome (TSS) is a rare cause of shock typically caused by Staph aureus or Strep pyogenes, that produces a toxin that leads to rapid onset hypotension with a diffuse erythematous rash.
Signs of TSS may include rapid onset of altered mental status, dizziness, nausea, abdominal discomfort, hypotension, and rash
TSS is associated with foreign bodies, such as tampons or nasal packing - make sure to remove any offending object
Clindamycin is the drug of choice because it stops protein synthesis which helps treat toxic shock because toxic shock is caused by a protein (TSST-1) made by the bacteria.
TSS is associated iwth high morbidity and mortality despite treatments
Despite the association with TSS, there is little supporting evidence for prophylactic antibiotics when placing nasal packing

References

Gottlieb M, Long B, Koyfman A. The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature. J Emerg Med. 2018;54(6):807-814. doi:10.1016/j.jemermed.2017.12.048

Lange JL, Peeden EH, Stringer SP. Are prophylactic systemic antibiotics necessary with nasal packing? A systematic review. Am J Rhinol Allergy. 2017;31(4):240-247. doi:10.2500/ajra.2017.31.4454

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

Podcast 585: You Sure You Want Colchicine for Gout? Aug 10, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Gout is an arthritis caused by the deposition of urate crystals into the joint space
Colchicine works by disrupting microtubules and prevents white blood cells from getting into the joint space which stops the inflammatory response
Colchicine has a high rate of adverse events, in particular explosive diarrhea
The drug also has a very narrow therapeutic index and overdose is nearly universally fatal, with no antidote or effective treatment option available
Alternative agents such as steroids, which reduce the inflammatory response to urate crystals, along with NSAIDs may be better options for treatment

References

Angelidis C, Kotsialou Z, Kossyvakis C, et al. Colchicine Pharmacokinetics and Mechanism of Action. Curr Pharm Des. 2018;24(6):659-663. doi:10.2174/1381612824666180123110042

Finkelstein Y, Aks SE, Hutson JR, et al. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila). 2010;48(5):407-414. doi:10.3109/15563650.2010.495348

Dalbeth N, Merriman TR, Stamp LK. Gout. Lancet. 2016;388(10055):2039-2052. doi:10.1016/S0140-6736(16)00346-9

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

Podcast 584: Ketamine for Depression and Suicidality Aug 04, 2020

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Suicide is currently the 10th leading cause of death in the US
Low quality studies have reported ketamine as a potential promising agent in treating depression and preventing suicidal ideations or thoughts
Randomized study was performed looking at giving ketamine to depressed patients in the ED to see if they could establish a proof of concept, meaning: would looking at ketamine for treatment of acute depression or suicidality be viable?
18 suicidal patients who required hospitalization for their depression and suicidality were entered in the study. 88% of the group treated with ketamine felt like their symptoms improved for up to 3 days, while only 33% of the placebo group reported an improvement

References

Domany Y, Shelton RC, McCullumsmith CB. Ketamine for acute suicidal ideation. An emergency department intervention: A randomized, double-blind, placebo-controlled, proof-of-concept trial. Depression & Anxiety (1091-4269). 2020;37(3):224-233. doi:10.1002/da.22975.

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

Podcast 583: Raise Your Hands if You Have Carpal Tunnel Syndrome Aug 03, 2020

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Hand raising test: a simple but effective tool to diagnose carpal tunnel
Patients hold their hands over their head and if symptoms of carpal tunnel develop within 2 minutes, it is considered positive, meaning they likely have carpel tunnel
Symptom included numbness and dull pain in the distribution of the median nerve
Treatment for carpal tunnel in the ED can include splinting in a neutral position and oral steroids with possible follow up for steroid injections or surgery

References

Padua L, Coraci D, Erra C, et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol. 2016;15(12):1273-1284. doi:10.1016/S1474-4422(16)30231-9

Ma H, Kim I. The diagnostic assessment of hand elevation test in carpal tunnel syndrome. J Korean Neurosurg Soc. 2012;52(5):472-475. doi:10.3340/jkns.2012.52.5.472

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

Rapid Fire Pharmacy Review with Adis Keric of ER-Rx Jul 29, 2020

Show notes

Meet Adis Keric, Board Certified Pharmacotherapy Specialist and a Board Certified Critical Care pharmacist who works in the Emergency Department and ICU of level 1 trauma center Regions Hospital in Saint Paul, MN. Adis is the founder and host of a new FOAMed podcast, ER-Rx. He started the podcast to inform clinicians in the ED and ICU about up-to-date, appropriate and optimal use of medications in different clinical scenarios.

Dr. Nick Tsipis sits down with Adis to discuss some pearls in Emergency Medicine Pharmacy.

Time Stamps:

0:10 Intros

4:35 Antibiotics

8:30 Post-Intubation Sedation

12:00 Anti-coagulation reversal*

16:00 ER-Rx Plug

*Correction to figures quoted on anticoagulation reversal pricing. High-dose Andexxa regimen maxes out around $60,000 and Kcentra maxes out at $6,000. So there is still a massive price difference, but not as high as quoted in the audio.

Check out ER-Rx on iTunes, Google Podcasts, Spotify, YouTube and other major podcast hosting platforms!

Instagram: @errxpodcast

Website: http://errxpodcast.com/

Podcast 582: Gadolinium - The Contrast of MRI Jul 28, 2020

Show notes

Contributor: Michael Hunt, MD

Educational Pearls:

Contrast agents are commonly used for X-rays and CT's to better characterize disease, but contrast doesn't work with MRI. That's where the element Gadolinium comes into play.
Gadolinium, element 64, is ferromagnetic (attracted to iron) below 68 degrees and above that temperature it's paramagnetic which makes it useful in MRI (Magnetic Resonance Imaging).
Gadolinium is toxic alone, but when paired with chelators it can be used in humans and allows for better characterization of tumors or abnormal tissue on MRI.
It helps identify this abnormal tissue because when MRI causes polarization of our body's cells, the gadolinium, which has the maximum number of unpaired electrons in its orbital shells, alters the rate of decay in abnormal tissue highlighting abnormalities on imaging.
Gadolinium can also be used in the treatment of cancers because it collects in the cells of abnormal tissue, allowing for more targeted therapies.
In people exposed to gadolinium, the anaphylaxis rate is low, below 1/1000, and in rare cases there are reports of kidney injury and nephrogenic systemic fibrosis which is why it's not recommended in renal failure patients.

References

1)Ibrahim MA, Hazhirkarzar B, Dublin AB. Magnetic Resonance Imaging (MRI) Gadolinium. [Updated 2020 Mar 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482487/

2)Pasquini L, Napolitano A, Visconti E, et al. Gadolinium-Based Contrast Agent-Related Toxicities [published correction appears in CNS Drugs. 2018 May 15;:]. CNS Drugs. 2018;32(3):229-240. doi:10.1007/s40263-018-0500-1

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

Podcast 581: Alcohol Complications Jul 27, 2020

Show notes

\Contributor: Don Stader, MD

Educational Pearls:

Altered mental status/confusion are major symptoms associated with both alcohol use and withdrawal.
Wernicke's encephalopathy is a triad of symptoms of confusion, internuclear ophthalmoplegia, and confabulation
The treatment for Wernicke's is IV thiamine or vitamin B1
Untreated Wernicke's leads to Korsakoff's syndrome where a prolonged thiamine deficiency leads to worsening brain function
Subdural hematomas from torn bridging veins are common in alcoholics because of the combination of frequent falls and cerebral atrophy caused by alcohol.
Alcohol is a major cause of heart failure and atrial fibrillation; "holiday heart" is a-fib induced by binge drinking where high levels of acetaldehyde from the metabolism of alcohol excite the heart.
Frequent alcohol use is linked to esophageal cancer
Alcoholic cirrhosis can lead to a multitude of complications including esophageal varices that can rupture often with fatal outcomes
Aspiration pneumonia is more common in alcoholics because of a depressed gag reflex and alteration of oral flora

References

Brousse G, Geneste-Saelens J, Cabe J, Cottencin O. Alcool et urgences [Alcohol and emergencies]. Presse Med. 2018;47(7-8 Pt 1):667-676. doi:10.1016/j.lpm.2018.06.001

Chandrakumar A, Bhardwaj A, 't Jong GW. Review of thiamine deficiency disorders: Wernicke encephalopathy and Korsakoff psychosis. J Basic Clin Physiol Pharmacol. 2018;30(2):153-162. Published 2018 Oct 2. doi:10.1515/jbcpp-2018-0075

Simou E, Britton J, Leonardi-Bee J. Alcohol and the risk of pneumonia: a systematic review and meta-analysis. BMJ Open. 2018;8(8):e022344. Published 2018 Aug 22. doi:10.1136/bmjopen-2018-022344

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

On The Streets #6: Artificial Intelligence Detection for LVOs Jul 22, 2020

Show notes

Meet Michelle Whaley, Clinical Nurse Specialist and Stroke Program Coordinator at Sky Ridge Medical Center in Lone Tree, Colorado. Jordan and Michelle discuss advances in Artificial Intelligence technology in an app that uses algorithms to analyze CT Angiograms to alert physicians of patients with images concerning for Large Vessel Occlusions (LVOs). Listen as they discuss the sweeping implications of this technology in the realm of stroke care and how it is decreasing wait times for critical patients to receive tPA and interventional procedures.

For EMS, this technology is already improving the care given by specialized transfer teams of patients from smaller hospitals to regional stroke centers. Tune in for other applications of this technology in pre-hospital settings on the horizon.

Disclaimer: This episode of On The Streets is for educational purposes only. Emergency Medical Minute is not affiliated with VIZ AI in any way and did not receive compensation for this episode.

Podcast 580: Origin of PPE Jul 21, 2020

Show notes

Contributor: Michael Hunt, MD

Educational Pearls:

PPE, or personal protective equipment, has become a major talking point since the emergence of the novel coronavirus (COVID 19).
While ubiquitous now, there was not always equipment to protect health care providers or patients from infectious exposures.
The invention of surgical gloves are credited to surgeon William Halsted. He developed gloves because one of his assistants (and later wife), Carol Hampton, was having severe irritation due to a caustic pre-op disinfecting process. They developed the rubber glove for Hampton which garnered popularity, and by the early 20th century, half of surgeons were using rubber gloves.
Surgical masks came around during the same period as gloves. By 1919 about half of all surgeons were using masks, protecting themselves and their patients from infectious transmissions.
The simple advent of masks and gloves led to incredible reductions in morbidity and mortality in surgical cases. Now these simple barriers are key in the prevention of further transmitting of COVID-19.

References

1. Kean, Sam. "Glove at First Sight." podbean.com, 27 Apr. 2020, disappearingspoon.podbean.com/e/glove-at-first-sight/.

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

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