Emergency Medical Minute

Latest Episodes:

UnfilterED Clips: A Toxicologist's Perspective on COVID-19, Biological Warfare and the Need for Disaster Preparedness Jun 27, 2020

Show notes

Taken from 'UnfilterED #8: Dr. Christopher Hoyte'.

"This current sars-coV-2 / COVID-19 situation should really be a wake-up call for not just a pandemic, but for a biological attack...One of the things I would like to do when we bring our attention back from COVID and get through this pandemic is to really start to prepare for disaster preparedness on the level and scale that we need to for a biological attack and get our hospitals ready, my poison center ready, state and local governments ready so that we can meet that challenge when it happens." - Dr. Chris Hoyte

Dr. Chris Hoyte is an ED physician, toxicologist and researcher based in Denver, CO. He was featured in Bring Em' All: Chaos. Care. Stories from Medicine's Front Line, a book celebrating emergency physicians through personal testimonies and photography on the frontlines captured by legendary photographer, Eugene RIchards.

Photo © courtesy Eugene Richards

UnfilterED #8: Dr. Christopher Hoyte Jun 24, 2020

Show notes

Time Stamps:

01:25 - Dr. Hoyte's Origin Story

05:01 - What Drew Dr. Hoyte to Medical Toxicology?

08:22 - Dr. Hoyte's Most Interesting Toxicology Cases

08:52 - King Cobra Bite
13:31 - Verapamil Overdose
16:47 - Mass Cyanide Poisoning

19:16 - The Looming Threat of Biological Warfare and the Need for Emergency Preparedness

25:07 - How COVID-19 Affected Dr. Hoyte's Job as a Toxicologist

30:19 - How Does the Rocky Mountain Poison and Drug Center Handle Its Large Workload

35:56 - Cannabinoid Exposures

42:05 - The Future of Toxicology

Publications from Dr. Hoyte:

A Characterization of Synthetic Cannabinoid Exposures Reported to the National Poison Data System in 2010

https://pubmed.ncbi.nlm.nih.gov/22575211/

An Outbreak of Exposure to a Novel Synthetic Cannabinoid

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3983965/

The Continued Impact of Marijuana Legalization on Unintentional Pediatric Exposures in Colorado

https://pubmed.ncbi.nlm.nih.gov/30288992/

Pediatric Death Due to Myocarditis After Exposure to Cannabis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965161/

Anaphylaxis to Black Widow Spider Antivenom

https://pubmed.ncbi.nlm.nih.gov/21641165/

Intro Music:

Backbay Lounge Kevin MacLeod (incompetech.com)

Licensed under Creative Commons: By Attribution 3.0 License

http://creativecommons.org/licenses/by/3.0/

Podcast 574: Cyanide Toxicity Jun 23, 2020

Show notes

Contributor: Nick Tsipis, MD

Educational Pearls:

Significant cyanide exposure most commonly occurs from fire/smoke exposure particularly when plastics are involved
Cyanide binds to cytochrome oxidase leading to the use of anaerobic metabolism which causes a profound lactic acidosis
Classic toxicity includes a rapid loss of consciousness, hypotension, bradycardia, respiratory depression, and seizures
Mild exposures can lead to nausea/vomiting, headaches, and other nonspecific symptoms.
Sometimes patients will complain of an almond taste.
Cyanide toxicity will manifest on labs by a profound anion gap acidosis with elevated lactate (but don't wait for them to ponder the diagnosis)
Antidote is hydroxocobalamin and sodium thiosulfate
Severe cyanide exposure will likely need ICU level care until the blood gas levels return to their baselines and the lactic acidosis resolves

References

Nickson Chris C, Australian Centre for Health Innovation at Alfred Health. Cyanide Poisoning • LITFL • CCC Toxicology. Life in the Fast Lane • LITFL • Medical Blog. https://litfl.com/cyanide-poisoning-ccc/. Published April 2, 2019. Accessed June 11, 2020.

Parker-Cote JL, Rizer J, Vakkalanka JP, Rege SV, Holstege CP. Challenges in the diagnosis of acute cyanide poisoning. Clin Toxicol (Phila). 2018;56(7):609‐617. doi:10.1080/15563650.2018.1435886

MacLennan L, Moiemen N. Management of cyanide toxicity in patients with burns. Burns. 2015;41(1):18‐24. doi:10.1016/j.burns.2014.06.001

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

Podcast 573: Arsenic Toxicity Jun 22, 2020

Show notes

Contributor: Nick Tsipis, MD

Educational Pearls:

Arsenic is a heavy metal that binds to multiple cellular enzymes and inhibits aerobic metabolism
It is primarily absorbed through the skin, respiratory and GI tract.
The classic symptoms of heavy metal exposure are GI irritation (watery diarrhea, vomiting and abdominal pain) with multisystem organ failure.
Neuropathy can present insidiously
Initial work up includes EKG, and basic lab work (expect a delayed rise in liver function tests).
Acute arsenic ingestions can sometimes show up on imaging as it is radioapaque
Diagnosis is usually made with the history and evidence of multisystem organ failure.
Treatment should be coordinated with your local Poison Control or toxicologist and involves predominantly supportive care along with chelating agents succimer (oral) or dimercaprol (intramuscular)

References

Long N. Arsenic toxicity • LITFL • Toxicology Library Toxicant. Life in the Fast Lane • LITFL • Medical Blog. https://litfl.com/arsenic-toxicity/. Published August 25, 2019.

Kuivenhoven M, Mason K. Arsenic (Arsine) Toxicity. [Updated 2019 Apr 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541125/

Preview: The Black Doctors Podcast Jun 21, 2020

Show notes

In addition to producing our own content, we believe in using our platform to amplify other voices and perspectives in medicine. With that in mind, check out 'The Black Doctor Podcast' from Dr. Steven Bradley which features interviews with leading minority professionals of the current generation as well as stories of how they overcame adversity and attained their goals. "Listen and be inspired."

Podcasts available on Apple Podcasts, Spotify and all other major streaming platforms

Twitter: @StevenBradleyMD

Instagram: @theblackdoctorspodcast

Podcast 572: Locked In Syndrome Jun 16, 2020

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Locked in syndrome results typically from an infarct of the basilar artery leading to infarction of the brainstem but typically preservation of the higher structures
The result is complete paralysis with preserved cognitive function, hence the name
Because of their location within the brainstem, ocular movements are sometimes preserved, allowing a patient who recovers from the initial injury to communicate
Patients typically do not regain any motor function and have a poor prognosis of recovery
Thrombectomy of the basilar artery is sometimes considered even late after the initial presentation given the devastating prognosis

References

Smith E, Delargy M. Locked-in syndrome. BMJ. 2005;330(7488):406‐409. doi:10.1136/bmj.330.7488.406

Buchman SL, Merkler AE. Basilar Artery Occlusion: Diagnosis and Acute Treatment. Curr Treat Options Neurol. 2019;21(10):45. Published 2019 Sep 26. doi:10.1007/s11940-019-0591-0

Meinel TR, Kaesmacher J, Chaloulos-Iakovidis P, et alMechanical thrombectomy for basilar artery occlusion: efficacy, outcomes, and futile recanalization in comparison with the anterior circulationJournal of NeuroInterventional Surgery 2019;11:1174-1180.

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

Podcast 571: Digital Blocks Jun 15, 2020

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Traditional digital block involves dorsal approach on either side of the digit, injecting local anesthetic along each side to numb all four nerves of the digit
Newer approach involves a single injection along the palmar surface at MCP joint
Recent study further compared a proximal vs distal single palmar (volar) injection with sites at the MCP and PIP joints
Injection sites achieved similar anesthesia between groups but PIP injection site had faster time of onset - 2.5 minutes compared to 3.8 minutes

References

Choi S, Cho YS, Kang B, Kim GW, Han S. The difference of subcutaneous digital nerve block method efficacy according to injection location. Am J Emerg Med. 2020;38(1):95‐98. doi:10.1016/j.ajem.2019.04.031

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

Podcast 570: Oh no no no to O2 Jun 09, 2020

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Supplemental oxygen is not a completely benign intervention.
A recent meta-analysis found that O2 saturations above 96% while on supplemental O2 were associated with worse outcomes.
Only start a patient on supplemental oxygen if absolutely necessary and aim for a goal of no higher than 96%

References

Derek K Chu, Lisa H-Y Kim, Paul J Young, Nima Zamiri, Saleh A Almenawer, Roman Jaeschke, Wojciech Szczeklik, Holger J Schünemann, John D Neary, Waleed Alhazzani. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. The Lancet. Volume 391, Issue 10131. 2018. Pages 1693-1705,

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

Podcast 570: Oh no no no to O2 Jun 09, 2020

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Supplemental oxygen is not a completely benign intervention.
A recent meta-analysis found that O2 saturations above 96% while on supplemental O2 were associated with worse outcomes.
Only start a patient on supplemental oxygen if absolutely necessary and aim for a goal of no higher than 96%

References

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

Podcast 569: The eFAST Exam Jun 08, 2020

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:.

Focused assessment with Sonography for Trauma (FAST) exam and the extended-FAST (eFAST) are essential components of current trauma care and evaluation
There has been an accumulation of research to provide an estimate of effectiveness of identifying certain injuries with ultrasound:
- For identifying a pneumothorax, the sensitivity ~70% and specificity ~99%.
- For pericardial effusions, sensitivity 90% and specificity ~ 94%.
- For hemoperitoneum, sensitivity ~74% and the specificity ~98%.
While ultrasound is excellent for identifying many injuries, it may not be adequate alone to rule out serious injuries if the clinical suspicion is high based on these pooled studies

References

Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM. 2019;21(6):727‐738. doi:10.1017/cem.2019.381

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

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