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 563: DC ACs May 18, 2020

Show notes

Contributor: Nick Hatch, MD

Educational Pearls:

An AC (acromioclavicular joint) separation in the shoulder is a common traumatic injury
XRs can help rule out other injuries as well as help with grading the injury
There are six different grades for AC separations:
- Grade I: is stretching of the AC ligament without disruption or displacement of the clavicle and recovers with time.
- Grade II: is partial tearing of the AC ligament with some displacement but will also heal with time.
- Grade III: is a full separation with ligament rupture and may require surgery but is not always indicated. Surgery is more common in active patients.
- Grades IV, V, and VI are severe separations and all require surgery.
Other ligament damage or tears, like a slap injury, can mimic an AC separation and often require surgery but should remain on the differential diagnosis when working up shoulder trauma.
Setting expectations is key. Patients with a grade 1 or 2 separation should expect 6+ weeks of limited range of motion and up to 12 weeks until return to full function.
Cosmetically there may be a persistent bump on the shoulder.

References

van Bergen CJA, van Bemmel AF, Alta TDW, van Noort A. New insights in the treatment of acromioclavicular separation. World J Orthop. 2017;8(12):861‐873. Published 2017 Dec 18. doi:10.5312/wjo.v8.i12.861

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

COVID-19 Digest: Could Cigarette Smoking Actually be Protective Against COVID? May 13, 2020

Show notes

Host: Elizabeth Esty, MD.

Smoking is known to increase both susceptibility and severity of all manner of colds and pneumonias, so you'd think the world's 1.1 billion smokers would be at risk in this pandemic of what at first seemed to be a just a respiratory virus.

What's more, tobacco smoking increases risk for COPD, diabetes and coronary disease, so it may increase risk for more severe COVID indirectly. So it's remarkable that preliminary evidence suggests that smokers may be less likely to be harmed by COVID than non-smokers. A story that's gotten a fair amount of attention in the media concerns reports from France that smoking may be protective against COVID. We took a closer look and found that similar reports are coming in from across the globe, including the US. We decided to take some time to look at papers and attempt to explain this relationship.

Research By: Elizabeth Esty, MD.

Sound Editing By: Nathan Novotny.

References:

[1] Miyara M, Tubach F, Pourcher V, et al. Low incidence of daily active tobacco smoking in patients with symptomatic COVID-19. Qeios. April 2020. doi:10.32388/WPP19W.3

[2] Guan W, Ni Z, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine. 2020;382(18):1708-1720. doi:10.1056/NEJMoa2002032

[3] Chow N, Fleming-Dutra K, Gierke R, et al. Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(13):382-386. doi:10.15585/mmwr.mm6913e2

[4] Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. April 2020. doi:10.1001/jama.2020.6775

[5] Berlin I, Thomas D, Le Faou A-L, Cornuz J. COVID-19 and Smoking. Nicotine Tob Res. doi:10.1093/ntr/ntaa059

[6] Farsalinos K, Niaura R, Houezec JL, et al. Editorial: Nicotine and SARS-CoV-2: COVID-19 may be a disease of the nicotinic cholinergic system. Toxicology Reports. doi:10.1016/j.toxrep.2020.04.012

Photo Sourced From:

https://www.henryford.com/blog/2020/04/smoking-and-vaping-increase-covid-risks

Podcast 562: COVID-19 Occlusions May 12, 2020

Show notes

Contributor: Nick Tsipis, MD

Educational Pearls:

Case series reported 5 cases of generally young and healthy patients with COVID-19 who presented to the ER with acute stroke
Now several case series showing cardiovascular involvement or complications related to COVID-19
While these case series may shed light on the nature of COVID-19 complications, it's worth remembering that so far these cases represent a few unique instances and we need more studies and data to pronounce COVID-19 infected patients at higher risk of thromboembolic events like strokes and heart attacks

References

Oxley, T. et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. April 28, 2020. DOI: 10.1056/NEJMc2009787

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

Podcast 561: Give Bup May 11, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Buprenorphine has been shown to decrease morbidity and mortality in opioid use disorder
Buprenorphine used in naloxone-induced withdrawals can displace naloxone at opioid receptors, leading to reduced withdrawal symptoms and lessen the chance of using after discharge
Patients in acute withdrawal due to naloxone after an overdose should be given Buprenorphine. Data shows that withholding Buprenorphine leads to increased mortality rates of 5% within the following month, and 10% in the following year.

References

Herring, Andrew. "Emergency Department Medication-Assisted Treatment of Opioid Addiction." Chcf.org, Aug. 2016, www.chcf.org/wp-content/uploads/2017/12/PDF-EDMATOpioidProtocols.pdf.
D.H. Cisewski et al. Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting. American Journal of Emergency Medicine 37 (2019) 143–150

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

COVID-19 Digest: Bacille Calmette-Guérin (BCG) Vaccine for Treating COVID-19 May 08, 2020

Show notes

In the US, few people receive vaccination for tuberculosis (TB), a disease that hasn't been a major killer here for many decades. But while we in the US mostly experience TB as a relatively rare but real threat in its multidrug resistant form, particularly in pts with HIV--or in Victorian novels--TB still kills 2 million people a year. There is a vaccine for TB, a live attenuated vaccine called BCG for Bacille Calmette-Guerin. In fact it's the most widely used vaccine on earth, and an estimated 4 billion people have received it since was first administered to a baby whose mother died of TB a few hours after giving birth in the summer of 1921.

This connection of this vaccine to COVID caught our attention when a friend suggested a few weeks ago that Russia and other parts of the world where BCG vaccination is routine might be shielded from the worst COVID outbreaks. In the intervening weeks, as Russia grapples with its own COVID epidemic, that possibilty seems less tenable, but it did lead us down an interesting research path.

Host: Elizabeth Esty, MD

Research By: Elizabeth Esty, MD

Sound Editing By: Nate Novotny

References:

Miller A, Reandelar MJ, Fasciglione K, Roumenova V, Li Y, Otazu GH. Correlation between Universal BCG Vaccination Policy and Reduced Morbidity and Mortality for COVID-19: An Epidemiological Study. Epidemiology; 2020. doi:10.1101/2020.03.24.20042937
Kleinnijenhuis J, Quintin J, Preijers F, et al. Bacille Calmette-Guerin induces NOD2-dependent nonspecific protection from reinfection via epigenetic reprogramming of monocytes. Proceedings of the National Academy of Sciences. 2012;109(43):17537-17542. doi:10.1073/pnas.1202870109
Arts RJW, Moorlag SJCFM, Novakovic B, et al. BCG Vaccination Protects against Experimental Viral Infection in Humans through the Induction of Cytokines Associated with Trained Immunity. Cell Host & Microbe. 2018;23(1):89-100.e5. doi:10.1016/j.chom.2017.12.010

Further Reading:

https://www.who.int/news-room/commentaries/detail/bacille-calmette-gu%C3%A9rin-(bcg)-vaccination-and-covid-19

https://clinicaltrials.gov/ct2/show/NCT04328441

https://www.mpg.de/14491738/0219-mpin-116799-modified-tuberculosis-vaccine-as-a-therapy-for-cancer-of-the-bladder

Podcast 560: Imaging in a COVID world May 07, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

COVID-19 commonly appears as a bilateral patchy infiltrate on chest radiograph, but this is a non-specific finding
- Sensitivities range from 17-70% for COVID-19
- Many other viral pneumonias such as RSV and influenza can have similar findings
Point-of-care ultrasound (POCUS) demonstrates B-lines, water-fall sign, or hepatization of the lung, but these are also non-specific
Computerized tomography (CT) appears to be one of the more sensitive tests for detecting COVID-19, demonstrating ground-glass opacities - often before or without the patient having symptoms
- However, routine use of CT for diagnosis COVID-19 is strongly discouraged by many medical societies and the CDC
Imaging may not be necessary in most patients presenting with suspected COVID-19 for multiple reasons:
- Diagnosis is often clinical suspicion, with or without confirmatory PCR testing (if available)
- Imaging does little to change the management in the majority of patients with COVID-19
- Obtaining imaging exposes additional healthcare workers
- Cleaning protocols for units (especially CT) can be extensive and require significant downtime of the machine, thereby leading to delays in care

References

Farkas, Josh. "COVID-19." EMCrit Project, 21 Apr. 2020, emcrit.org/ibcc/covid19/#labs.
Guan W. et al. Clinical Characteristics of Coronavirus Disease 2019 in China. February 28, 2020, updated on March 6, 2020, at NEJM.org. DOI: 10.1056/NEJMoa2002032

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

Mental Health Monthly #3: Maintaining Mental Health and Wellness for Healthcare Professionals May 06, 2020

Show notes

In this timely installment of Mental Health Monthly, mental health expert Lexi Eliades shares useful tips for identifying burnout and mental health decline as well as ways to maintain mental wellness amidst adversity and significant stress. We at Emergency Medical Minute know many of our listeners are on the frontlines of the COVID-19 pandemic. We hope this piece is helpful and that it reaches someone who needs to hear it!

Podcast 559: Metabolic Acidosis May 05, 2020

Show notes

Contributor: Dylan Luyten, MD

Educational Pearls

Acidosis can be caused by a respiratory, metabolic, or mixed source
A respiratory acidosis will have a low serum pH and elevated bicarbonate if it's chronic, but most importantly end tidal CO2 or arterial CO2 will be high.
With a metabolic acidosis we expect to see a low serum pH and low serum bicarbonate.
Once it's determined a patient is in a metabolic acidosis, we need to determine if it's an elevated anion gap or normal anion gap acidosis. Anion gap is calculated by subtracting the serum anions from the cations, or serum sodium minus the serum chloride and CO2 (Na-(Cl+CO2)). A normal gap is 6-10, gaps over 10 have an elevated anion gap acidosis.
The causes of an elevated anion gap acidosis can be remembered with MUDPILES mnemonic (Methanol, Uremia (renal failure), Diabetes/DKA, Paraldehyde, Isoniazid, Lactate, Ethanol/Ethylene glycol, salicylates/aspirin).
So when you suspect an elevated gap acidosis you need to evaluate for all causes, so you need to get an venous or arterial blood gas along with lactate, salicylate, and Tylenol levels.

References

Vanmassenhove J. Lameire N. Approach to the patient presenting with metabolic acidosis. Acta Clin Belg. 2019 Feb;74(1):21-27. doi: 10.1080/17843286.2018.1547245. Epub 2018 Nov 24.
Burger MK, Schaller DJ. Physiology, Acidosis, Metabolic. [Updated 2019 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482146/

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Podcast 558: Rapid ARDS Review May 04, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Acute respiratory distress syndrome (ARDS) is a catch all term for when lung injury leads to fluid collection in the air spaces of the lungs

Ventilatory management in ARDS patients involves lower FiO2 and PEEP than other patients and relies on lung protective ventilation strategies to prevent barotrauma

Proning these patients has also been utilized with the goal of matching V/Q, or getting good blood flow to areas of the lung which are well ventilated.

References

1. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. N Engl J Med 2004; 351:327-336. DOI: 10.1056/NEJMoa032193

2. Howell MD, Davis AM. Management of ARDS in Adults. JAMA. 2018;319(7):711–712. doi:10.1001/jama.2018.0307

3. Scholten, E.L. et al. Treatment of ARDS With Prone Positioning. Chest. 2017 Jan;151(1):215-224. doi: 10.1016/j.chest.2016.06.032. Epub 2016 Jul 8.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

COVID-19 Digest: Strokes in Young People with COVID May 01, 2020

Show notes

Last week we looked at neurologic presentations of COVID-19; this week we'll look more closely at strokes in young people with COVID. A letter published 2 days ago in the NEJM with lead author Thomas Oxley, the Neuro ICU director at Mt Sinai, presents five case studies of relatively young patients who had strokes at home and presented to Mt Sinai between 23 March and 7 April. In pre-COVID days, Mt Sinai saw on about 3 patients under the age of 50 with strokes per month, so 5 in 2 weeks represents a 7-fold increase. The authors call this one of the clearest and most profound correlations" they've come across. Though strokes in other COVID case reports are also occurring in older pts, other centers are reporting similar increases in young people with few or no risk factors presenting with major strokes. Right now there are at least 3 US centers preparing to publish data on the stroke in young people phenomenon.

Host: Elizabeth Esty, MD

Research By: Elizabeth Esty and Nate Novotny

Sound Editing By: Stephen Bahmani

References:

Oxley TJ, Mocco J, Majidi S, et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. New England Journal of Medicine. 2020;0(0):e60. doi:10.1056/NEJMc2009787
Cha AE. Young and middle-aged people, barely sick with covid-19, are dying of strokes. Washington Post. https://www.washingtonpost.com/health/2020/04/24/strokes-coronavirus-young-patients/. Published April 25, 2020.
Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. April 2020. doi:10.1016/j.thromres.2020.04.013

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