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 550: Good ol' Versed Mar 17, 2020

Show notes

Contributor: Sam Killian, MD

Educational Pearls:

Agitation can be due to a number of causes, but regardless of the cause, sedation often plays a key role in patient and provider safety. But what is the best sedative agent?
A study looked at control of agitation with intramuscular medication. Specifically, 5 different IM sedative agents were compared to see which one best provides "adequate" sedation in 15 minutes or less.
Haldol 5mg, Haldol 10mg, Versed 5mg, Zyprexa 10mg, and Geodon 20mg were all compared, and by far Versed provided the best sedative results. All medications had approximately the same amount of adverse effects.
There are so many sedative options, but time and time again large dose benzodiazepines have demonstrated great effectiveness in treating acute agitation

References

1) Klein, Lauren R. et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Annals of Emergency Medicine. 2018. 72(4), 374 - 385

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

Podcast 549: Just Use Epineprhine Mar 16, 2020

Show notes

Contributor: Sam Killian, MD

Educational Pearls:

Classic dogma teaching that epinephrine should not be used in the fingers, nose, penis, and toes when performing local anesthesia due to concerns for ischemia is wrong
This has been well documented in multiple literature reviews
A prospective, randomized double-blind study compared lidocaine vs lidocaine with epinephrine for finger injuries and the use of epinephrine was associated with less bleeding and better anesthesia

Editor's note: in the lidocaine without epinephrine group, 5 (not 7) needed additional dosing of local anesthesia. The groups were also split 29 for lidocaine alone and 31 for lidocaine with epinephrine but we're in a pandemic so who is noticing anyways

References

1. Wilhelmi, B.J., et al. Do not use epinephrine in digital blocks: myth or truth? Plast Reconstr Surg. 2001 Feb;107(2):393-7.
2. Ilicki, J. Safety of Epinephrine in Digital Nerve Blocks: A Literature Review. J Emerg Med. 2015 Nov;49(5):799-809. doi: 10.1016/j.jemermed.2015.05.038. Epub 2015 Aug 4.
3. Walsh, K., Baker, B.G., Iyer, S. Adrenaline Auto-injector injuries to digits; a systematic review and recommendations for emergency management. 2020 Feb 8. pii: S1479-666X(20)30016-0. doi: 10.1016/j.surge.2020.01.005.

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

On the Streets #2: Neurological Deficits Mar 11, 2020

Show notes

Part 1 of 2: Dr. Adam Graham dishes out the essentials of identifying concerning neurological deficits on the scene, predicting what they mean and how to best care for patients with neurological deficits in the pre-hospital setting.

About Dr. Adam Graham:

Adam Graham, MD, is a board-certified neurologist with Blue Sky Neurology in Denver. His professional interests include treatment of diseases of the peripheral nerves and muscles, for example ALS, myasthenia gravis and peripheral neuropathy. He works to make EMG procedures as comfortable as possible for patients. Dr. Graham earned his medical degree from Creighton University. He then completed a residency in neurology and a fellowship in neuromuscular medicine and EMG, both at the University of Colorado.

Podcast 548: Adrenal Crisis Mar 10, 2020

Show notes

Contributor: Nick Tsipis, MD

Educational Pearls:

Congenital adrenal hyperplasia (CAH) is a group of enzyme deficiencies in the adrenals leading to a deficiency of hormones normally synthesized by the adrenals (mineralocorticoids, glucocorticoids, androgens)
21-hydroxylase is most commonly the deficient enzyme.
21-hydroxylase is needed to produce aldosterone and cortisol, and those with chronic cortisol deficiencies need daily steroid replacement
Aldosterone, made in the kidney as part of the renin-angiotensin-aldosterone system (RAAS), increases blood pressure via salt and water retention to maintain adequate organ perfusion
Adrenal crisis results in a loss of cortisol leading to hypoglycemia and potential CNS depression with hypotension, hypoglycemia, and hyponatremia
Patients in adrenal crisis need salt, volume, and glucose replacement

References

Martin-Grace, J., et al. Adrenal insufficiency: physiology, clinical presentation and diagnostic challenges. Clin Chim Acta. 2020 Feb 6.

Dineen, R., Thompson, C.J., Sherlock, M. Adrenal crisis: prevention and management in adult patients. Ther Adv Endocrinol Metab. 2019 Jun 13;10:2042018819848218.

El-Maouche, D., Arlt, W., Merke, D.P. Congenital Adrenal Hyperplasia. Lancet. 2017 Nov 11;390(10108):2194-2210.

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

Podcast 547: Capsaicin Cream to the Rescue Mar 09, 2020

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

A recent retrospective study looked capsaicin cream in treating cannabinoid hyperemesis syndrome in regards to length of stay, cost analysis, use of rescue therapies, and adverse events
Results showed a trend towards reduced length of stay but did not reach statistical significance
Use of opioids was reduced in the capsaicin group
Capsaicin remains a potential treatment option in this often difficult disease

References

Samantha Wagner, Jason Hoppe, Matthew Zuckerman, Kerry Schwarz & Julie McLaughlin (2019) Efficacy and safety of topical capsaicin for cannabinoid hyperemesis syndrome in the emergency department, Clinical Toxicology, DOI: 10.1080/15563650.2019.1660783

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

Podcast 546: Complete Heart Block Mar 03, 2020

Show notes

Author: Jared Scott, MD

Educational Pearls:

Differentiating symptomatic bradycardia from asymptomatic may be essential in determining workup and treatment
Airway, breath, circulation always hold true
Symptoms may include dizziness, syncope, or weakness
An EKG is essential in the majority of cases
Complete heart block can be a cause of symptomatic bradycardia and requires immediate attention
Complete heart block can be caused by drugs (beta-blockers, calcium channel blockers), Lyme disease, infiltrative disease, or degeneration of the conduction system

References:

Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019;74(7):e51. Epub 2018 Nov 6.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Podcast 545: So You Quit Smoking… Now What? Mar 02, 2020

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

New data shows within 5 years of smoking cessation, the risk of cardiovascular disease becomes half of those who continue to smoke
After 10-15 years of cessation, cardiovascular disease rates return to rates seen in non-smokers.
Lung disease, COPD, and cancer rates do not decrease quite as rapidly, but do decrease
It's important to remind patients of the long-term health benefits associated with smoking cessation when counseling them.

References

Duncan MS, Freiberg MS, Greevy RA, Kundu S, Vasan RS, Tindle HA. Association of Smoking Cessation With Subsequent Risk of Cardiovascular Disease. JAMA. 2019;322(7):642–650. doi:10.1001/jama.2019.10298

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

UnfilterED #5: Dr. Lisa Zwerdlinger Feb 26, 2020

Show notes

Recorded remotely in the highest hospital in the world, Nick sits down to talk with Dr. Lisa Zwerdlinger, a small-town physician who's worn many different hats both in the hospital and her community.

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 544: C is for Sepsis Feb 25, 2020

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

Previously, trials had shown promising evidence that vitamin C may improve mortality rates in patients with sepsis or septic shock.
A 2017 retrospective before-after study gave a "cocktail" of hydrocortisone, vitamin C, and thiamine to patients with severe sepsis or in septic shock and reported a decrease in mortality from 40% to 8%.
A 2020 randomized controlled trial demonstrated that giving patients hydrocortisone, vitamin C, and thiamine showed no benefits in improving sepsis outcomes.
Currently use of Vitamin C in sepsis and septic shock remains controversial due to lack of sufficient data

References

1) Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229. Epub 2016 Dec 6.

2) Fujii T, Luethi N, Young PJ, et al. Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS Randomized Clinical Trial. JAMA. 2020;323(5):423–431. doi:10.1001/jama.2019.22176

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

Podcast 543: Scoring Blunt Traumatic Aortic Injury Feb 24, 2020

Show notes

Author: Nick Tsipis, MD

Educational Pearls:

Aortic injury caused by blunt trauma is very rare
Chest x-ray findings might include widening of the mediastinum
Ligamentum arteriosum (remnant of the ductus arteriosus) tethers the aorta to the chest wall, potentially causing injury with abrupt decelerations and motion
XR lacks significant sensitivity (around 75%) to be utilized in many cases
CT angiogram (CTA) of the chest is typically the preferred test but comes with potential risks including radiation exposure
NEXUS Decision Instrument (NEXUS DI) is a scoring tool that may provide value in determining the need for additional imaging

References

Yu L, Baumann BM, Raja AS, Mower WR, Langdorf MI, Medak AJ, Anglin DR, Hendey GW, Nishijima D, Rodriguez RM. Blunt Traumatic Aortic Injury in the Pan-scan Era. Acad Emerg Med. 2019 Dec 7. doi: 10.1111/acem.13900.

Summarized and edited by Erik Verzemnieks, MD

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