Emergency Medical Minute

Latest Episodes:

Mental Health Monthly #2: Non-Epileptic Seizures (NES) Feb 19, 2020

Show notes

Non Epileptic Seizures (NES) is perhaps one of the most misunderstood and overlooked disorders that emergency medicine professionals encounter. Dr. Randi Libbon & Dr. Laura Strom, both experts on NES, explain the ongoing research surrounding the topic as well as how to best manage patients with NES in the emergency setting.

To learn more about Dr. Randi Libbon:

https://www.cudoctors.com/Find_A_Doctor/Profile/25375

To learn more about Dr. Laura Strom:

http://www.ucdenver.edu/academics/colleges/medicalschool/departments/neurology/Faculty/Pages/Strom.aspx

References & Further Reading:

[1] Baslet G, Seshadri A, Bermeo-Ovalle A, Willment K, Myers L. Psychogenic Non-epileptic Seizures: An Updated Primer. Psychosomatics. 2016;57(1):1-17. doi:10.1016/j.psym.2015.10.004

[2] Perez DL, LaFrance WC. Nonepileptic Seizures: An Updated Review. CNS Spectr. 2016;21(3):239-246. doi:10.1017/S109285291600002X

[3] Libbon R, Gadbaw J, Watson M, et al. The feasibility of a multidisciplinary group therapy clinic for the treatment of nonepileptic seizures. Epilepsy Behav. 2019;98:117-123. doi:10.1016/j.yebeh.2019.06.032

[4] Ding J-R, An D, Liao W, et al. Altered Functional and Structural Connectivity Networks in Psychogenic Non-Epileptic Seizures. PLoS ONE. 2013;8(5). doi:10.1371/journal.pone.0063850

[5] Allendorfer JB, Nenert R, Hernando KA, et al. FMRI response to acute psychological stress differentiates patients with psychogenic non-epileptic seizures from healthy controls – A biochemical and neuroimaging biomarker study. NeuroImage Clin. 2019;24:101967. doi:10.1016/j.nicl.2019.101967

Podcast 542: Nasogastric Tubes Feb 18, 2020

Show notes

Author: Don Stader, MD

Educational Pearls:

Nasogastric tubes (NGT) are very uncomfortable for all those involved but some simple tricks and tips may help:
Topical lidocaine can be inserted into the nasal passage for local analgesia
Afrin may help shrink the mucosal tissue of the nasal turbinates as well
Molding the tube with cold/ice water can help - putting it in an ice bath with an endotracheal tube stylet will allow you to mold the tip to your preference

References

Lor YC, Shih PC, Chen HH, et al. The application of lidocaine to alleviate the discomfort of nasogastric tube insertion: A systematic review and meta-analysis. Medicine (Baltimore). 2018;97(5):e9746. doi:10.1097/MD.0000000000009746

https://www.acepnow.com/article/making-ng-tube-placement-less-horrendous/

https://www.aliem.com/trick-of-trade-making-ng-and-np-painless/

Summarized and edited by Erik Verzemnieks, MD

Podcast 541: Needle Thoracostomy Feb 17, 2020

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

Traditional technique of needle thoracostomy for tension penumothorax is along the 2nd intercostal space at the midclavicular line
Inserting a large angiocatheter along the 4th or 5th intercostal space at the mid-axillary line may provide a thinner area that is more easily identified, overcoming many of the obstacles of the traditional approach
The 10th Edition of ATLS now recommends this location as well
A finger thoracostomy, where a scalpel and then the finger are used to penetrate the pleural cavity at the same location, is another method to provide quick decompression of a traumatic tension pneumothorax, allowing a tube thoracostomy to be performed later

References

Laan DV, Vu TD, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2016;47(4):797–804. doi:10.1016/j.injury.2015.11.045

Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma. 2011 Nov;71(5):1099-103; discussion 1103. doi: 10.1097/TA.0b013e31822d9618.

Summarized and edited by Erik Verzemnieks, MD

On the Streets #1: The Art of the Handoff Report Feb 12, 2020

Show notes

EMM is proud to present the pilot episode of our new monthly series, "On the Streets". This will be an informative podcast for all of our listeners, but this one was designed specifically for our EMS listeners.

Each month, we will consult medical experts on topics pertinent to prehospital care: Identifying a posterior circulation stroke in the field; Knowing when to do a 12-lead and what to look for; How to use capnography for a variety of datapoints; How to give an effective handoff report. And much much more...

On our first episode, we are proud to welcome long-time friend of EMM, now retired Emergency Physician and current Medical Director of the ACC EMS program, Dr. Michael Hunt. This episode focuses exclusively on the Do's and Don'ts of giving handoff report.

As we all know, knowledge and timing can make a world of difference when treating acutely ill patients. Like all of our content, we aim to equip you with the resources to forge your medical knowledge while keeping it relevant and time-efficient. Tune into "On the Streets" for real, raw and relevant EMS education.

Photo Credit: https://www.flickr.com/photos/sc-axman/2327963351/

Podcast 540: Zyprexa Feb 11, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Olanzapine (Zyprexa) is an atypical antipsychotic that can be used in a similar fashion to haloperidol for pain and nausea, including that with abdominal pain and headaches
Olanzapine can be administered as an oral disolving tablets, intramuscular or intravenous injection
Because Zyprexa is an atypical antipsychotic, it has a lower risk for tardive dyskinesia and akathisia
Olanzapine may cause transient rises in glucose and should be considered when contemplating use in a diabetic

References

Olanzapine for the prevention and treatment of cancer-related nausea and vomiting in adults.Sutherland A, Naessens K, Plugge E, Ware L, Head K, Burton MJ, Wee B. Cochrane Database Syst Rev. 2018;9:CD012555. Epub 2018 Sep 21.

Silberstein, S.D., Peres, M.F., Hopkins, M.M., Shechter, A.L., Young, W.B. and Rozen, T.D. (2002), Olanzapine in the Treatment of Refractory Migraine and Chronic Daily Headache. Headache: The Journal of Head and Face Pain, 42: 515-518. doi:10.1046/j.1526-4610.2002.02126.

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

Podcast 539: Coricidin Abuse Feb 10, 2020

Show notes

Contributor: Rachel Beham, PharmD

Educational Pearls:

Coricidin HBP Cough & Cold (dextromethorphan and chlorpheniramine) is one of the more commonly abused over-the-counter medications
Dextromethorphan, binds to multiple receptors, particularly at high doses
- Opioid receptors, causing respiratory depression, CNS depression
- NMDA receptors, causing agitation and hallucinations
- Serotonin-reuptake inhibition, which may lead to serotonin syndrome, especially when combined with other agents
Dextromethorphan also contains bromide, which when chronically abused can lead to bromism (behavioral changes, hallucinations, weight loss, and neurologic changes)
Chlorpheniramine is an antihistamine and can cause anticholinergic effects in overdose, such agitation, hyperthermia, and hallucinations
Acute treatment of Coricidin abuse is mostly supportive, which may include benzodiazepines, naloxone, dialysis, sodium bicarbonate, and physostigmine depending on the predominate toxidrome and symptoms present

References

Ritter D, Ouellette L, Sheets JD, Riley B, Judge B, Cook A, Houseman J, Jones JS. "Robo-tripping": Dextromethorphan toxicity and abuse. Am J Emerg Med. 2019 Nov 17. pii: S0735-6757(19)30655-2. doi: 10.1016/j.ajem.2019.10.001.

Bryner JK, Wang UK, Hui JW, Bedodo M, MacDougall C, Anderson IB. Dextromethorphan abuse in adolescence: an increasing trend: 1999-2004. Arch Pediatr Adolesc Med. 2006;160(12):1217–1222. doi:10.1001/archpedi.160.12.1217

Monks S, Yen M, Myers J. Bromism: An overlooked and elusive toxidrome from chronic dextromethorphan abuse. Am J Emerg Med. 2019 Nov 15:158491. doi: 10.1016/j.ajem.2019.158491.

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

Podcast 538: Low Maintenance Boxer's Fracture Feb 04, 2020

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

A distal 5th metacarpal neck fracture is often referred to as a "boxer's fracture" and a common fracture encountered in the emergency department
Splinting with an ulnar gutter splint is the typical management of uncomplicated boxer's fractures
A recent study randomized patients to buddy taping or ulnar gutter splint for uncomplicated Boxer's fractures.
Similar functional and pain outcomes were found at follow-up, and those in the buddy taping group returned to work more quickly.
One limitation was nearly 20% of study patients were lost to follow up

Editor's note: remember - this only applies to a true boxer's fracture, which is a distal 5th metacarpal neck fracture, not just any 5th metacarpal shaft fracture

References

Richard Pellatt, Igor Fomin, Carli Pienaar, Randipsingh Bindra, Michael Thomas, Ezekiel Tan, Cindy Mervin, Ping Zhang, Gerben Keijzers. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial, Annals of Emergency Medicine, Volume 74, Issue 1, 2019, Pages 88-97,

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

Podcast 537: Thoughts on Cardiac Arrest Feb 03, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

High-quality compressions are an essential, and probably one of the most important, part of cardiac arrest
Actual evidence for drugs in cardiac arrest included in ACLS are limited, including epinephrine, bicarbonate, amiodarone, etc.
Early defibrillation for ventricular tachycardia (VT) or ventricular fibrillation (VF) has a plethora of supporting evidence
Double-sequential defibrillation (nearly simultaneous defibrillation using 2 machines) may be considered for refractory dysrhythmias like VF
tPA during a cardiac arrest can be considered in the setting of massive PE (although the evidence supporting this practice is poor)
Ending a cardiac arrest resuscitation is a difficult decision and use of ultrasound may be helpful to assess for meaningful cardiac function/activity

References

Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O'Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW . Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov;132(18 Suppl 2):S444-64.

Wang Y, Wang M, Ni Y, Liang B, Liang Z. Can Systemic Thrombolysis Improve Prognosis of Cardiac Arrest Patients During Cardiopulmonary Resuscitation? A Systematic Review and Meta-Analysis.J Emerg Med. 2019;57(4):478. Epub 2019 Oct 5.

Eric Cortez, William Krebs, James Davis, David P. Keseg, Ashish R. Panchal. Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest. Resuscitation. Volume 108. 2016. Pages 82-86,

Atkinson PR, Beckett N, French J, Banerjee A, Fraser J, Lewis D. Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators. Cureus. 2019;11(4):e4456. Published 2019 Apr 13. doi:10.7759/cureus.4456

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

UnfilterED #4: Dr. Vivek Tayal Jan 29, 2020

Show notes

Dr. Vivek Tayal of Carolinas Medical Center, a pioneer of using ultrasound in the emergency department, reflects on his role in establishing ultrasound use in emergency medicine and much more!

Ultrasound Program Management:

https://www.amazon.com/Ultrasound-Program-Management-Point-Care/dp/3319631411

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 536: Epistaxis 101 Jan 28, 2020

Show notes

Contributor: Dylan Luyten, MD

Educational Pearls:

Clear the nasal passages - have the patient, if stable, blow their nose to dislodge any clot that might be in the way
Searching for the source of bleeding can be tough. Majority of anterior bleeding is from Kesselbach's plexus
Placing a clamp to provide direct pressure is a mainstay of treatment
Application of a topical agent, which may include lidocaine epinephrine tetracaine (LET), tranexamic acid (TXA), or oxymetazoline
Nasal packing with a nasal balloon or merocel may be necessary if bleeding persists
Posterior epistaxis can be potentially devastating - for all practical purposes are epistaxis that does not resolve with anterior packing
Interventional radiology can be a helpful consultant for controlling of posterior epistaxis, and may be just as or more helpful than ENT

References

Supriya M, Shakeel M, Veitch D, Ah-See K. Epistaxis: prospective evaluation of bleeding site and its impact on patient outcome. J Laryngol Otol. 2010;124(7):744-749.

Shargorodsky J, Bleier B, Holbrook E, et al. Outcomes analysis in epistaxis management: development of a therapeutic algorithm. Otolaryngol Head Neck Surg. 2013;149(3):390-398.

Singer A, Blanda M, Cronin K, et al. Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial. Ann Emerg Med. 2005;45(2):134-139.

Womack JP, Kropa J Jimenez Stabile M. Epistaxis: Outpatient Management. Am Fam Physician. 2018 Aug 15;98(4):240-245.

Liu WH, Chen YH, Hsieh CT, Lin EY, Chung TT, Ju DT. Transarterial embolization in the management of life-threatening hemorrhage after maxillofacial trauma: a case report and review of literature. Am J Emerg Med. 2008 May;26(4):516.e3-5. doi: 10.1016/j.ajem.2007.07.036.

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

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