Emergency Medical Minute

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Health & Fitness
**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 #497: Does my patient with CP have ACS? Aug 15, 2019

Show notes

Author: Dylan Luyten, MD

Educational Pearls:

While certain aspects of the history, exam, and EKG may increase likelihood of ACS, there is no one element that performs well on its own
Elements of the history have been found to have different likelihood ratios, which can increase or decrease the probability of a patient having ACS
Likelihood ratios greater than one increase the chance of the patient having the disease. Ratios less than one decrease it
Bilateral arm radiation is one of very few historical features that increases the likelihood of ACS
ST depressions are one of the few EKG findings with a high LR for ACS
Scoring systems such as the HEART score can be useful to risk stratify your patients

References

Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?: The Rational Clinical Examination Systematic Review. JAMA. 2015 Nov 10;314(18):1955-65. doi: 10.1001/jama.2015.12735. Review. PubMed PMID: 26547467.

Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SH, van Tooren R, Mast TP, van den Akker F, Cramer MJ, Poldervaart JM, Hoes AW, Doevendans PA. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7. PubMed PMID: 23465250.

From CarePoint PA Academy, 2019

Podcast # 496: Hallucinogens Aug 12, 2019

Show notes

Author: David Holland, MD

Educational Pearls:

Hallucinogenics have been used for a variety of cultural and religious reasons for thousands of years
In the 1960's a Harvard professor began experimenting with psilocybin mushrooms. There was resulting public outcry, eventually leading to all hallucinogens being listed as schedule I drugs
Common hallucinogens include: LSD (acid), Mescaline (peyote), DMT (ayahuasca), Psilocybin (mushrooms), MDMA (ecstacy)
Effects vary by specific drug but may include auditory/visual hallucinations, increased empathy, loss of fear
Physiologic effects often include mydriasis, tachycardia, hyperthermia and hypertension
Recent neuroimaging studies have shown increased neural connectivity in people after administration of hallucinogens
Each hallucinogen has a specific dose and duration, some can last half a day or more

References

Heal DJ, Gosden J, Smith SL. Evaluating the abuse potential of psychedelic drugs as part of the safety pharmacology assessment for medical use in humans.Neuropharmacology. 2018 Nov;142:89-115. doi: 10.1016/j.neuropharm.2018.01.049. Epub 2018 Feb 8. Review. PubMed PMID: 29427652.

Garcia-Romeu A, Kersgaard B, Addy PH. Clinical applications of hallucinogens: A review. Exp Clin Psychopharmacol. 2016 Aug;24(4):229-68. doi: 10.1037/pha0000084. Review. PubMed PMID: 27454674; PubMed Central PMCID: PMC5001686.

Bogenschutz MP, Johnson MW. Classic hallucinogens in the treatment of addictions.Prog Neuropsychopharmacol Biol Psychiatry. 2016 Jan 4;64:250-8. doi: 10.1016/j.pnpbp.2015.03.002. Epub 2015 Mar 14. Review. PubMed PMID: 25784600.

From CarePoint PA Academy

Podcast # 495: Trauma in the Elderly Aug 06, 2019

Show notes

Author: Rachel Brady, MD

Educational Pearls:

Elderly patients (>65 years old) have a higher trauma mortality compared to younger patients, even though they have lower mechanisms of injury
Elder trauma is often under-triaged due to low-energy mechanisms and lack of physiologic response due to age and medications such as beta-blockers. Do not be reassured by normal vital signs.
Image elderly patients with head injury aggressively since they are at high risk of intracranial bleeds
Be sure to ask about anticoagulation use. Up to 15% of asymptomatic head injury patients on warfarin will have intracranial bleeds on CT.
Be on the lookout for unstable C-spine injuries such as type II odontoid fractures
Central cord syndrome is a possibility with any neck extension injury
Rib fractures are common, with mortality increasing greatly with more than 2 ribs involved
The elderly are more prone to musculoskeletal injuries due to loss of bone density
Always discuss goals of care with these patients

References

Rathlev NK, Medzon R, Lowery D, Pollack C, Bracken M, Barest G, Wolfson AB, Hoffman JR, Mower WR. Intracranial pathology in elders with blunt head trauma. Acad Emerg Med. 2006 Mar;13(3):302-7. doi: 10.1197/j.aem.2005.10.015. PubMed PMID: 16514123.

Keller JM, Sciadini MF, Sinclair E, O'Toole RV. Geriatric trauma: demographics, injuries, and mortality. J Orthop Trauma. 2012 Sep;26(9):e161-5. doi: 10.1097/BOT.0b013e3182324460. PubMed PMID: 22377505.

Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma.2000 Jun;48(6):1040-6; discussion 1046-7. doi: 10.1097/00005373-200006000-00007. PubMed PMID: 10866248.

Hashmi A, Ibrahim-Zada I, Rhee P, Aziz H, Fain MJ, Friese RS, Joseph B. Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2014 Mar;76(3):894-901. doi: 10.1097/TA.0b013e3182ab0763. Review. PubMed PMID: 24553567.

Brooks SE, Peetz AB. Evidence-Based Care of Geriatric Trauma Patients. Surg Clin North Am. 2017 Oct;97(5):1157-1174. doi: 10.1016/j.suc.2017.06.006. Review. PubMed PMID: 28958363.

Podcast #494: A Standard Toxicology Approach Aug 02, 2019

Show notes

Contributor: JP Brewer, MD

Educational Pearls:

Obtaining collateral is often vital to determine the potential drugs accessible to the patient - this may include
After this, use ancillary sources such as EMS, family/friends, and police to determine the patient's last normal, PMH and medications
To help separate toxidromes, pupillary exam and skin exam are helpful
Important physical exam clues in toxicology include the pupils and the skin
Adjunct laboratory evaluation may include liver function tests, acetaminophen level, salicylate levels, urine drug screens, particularly in unknown ingestions
Your local toxicologist (if you are fortunate to have one) or the Poison Center can always provide assistance in treatment and workup - consider involving them early

References

Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose. Emerg Med Clin North Am 2007; 25:249.

Podcast # 493: One Pill for the Kill Jul 31, 2019

Show notes

Contributor: JP Brewer, MD

Educational Pearls:

Because of their smaller size, there are a variety of adult-dose pills that are potentially toxic to children.
The most common categories of medications that may be toxic include cardiac, diabetic, pain, psychiatric, anti-malarial, and herbals/caustics
Oral hypoglycemics such as sulfonylureas can be particularly dangerous in children.
Opiates and benzodiazepines have the potential for respiratory arrest
Anti-malarial medications are arrhythmogenic to children
Camphor, batteries, oil of wintergreen (for the salicylate), and household caustic materials are dangerous non-pharmacologic ingestions to think about in children
If you encounter any of the above situations, consult your local poison control center 1-800-222-1222 or your toxicologist if you are lucky enough to have one on call

References

https://www.acep.org/how-we-serve/sections/toxicology/news/march-2016/one-pill-or-sip-can-kill/

Schillie SF, Shehab N, Thomas KE, Budnitz DS. Medication overdoses leading to emergency department visits among children. Am J Prev Med 2009;37:181-7.

Oz B, Levichek Z, Koren G. Medications That Can Be Fatal For a Toddler with One Tablet or Teaspoonful A 2004 Update. Pediatric Drugs, 2004; 6(2): 123-126

Podcast # 492: Pain While on Buprenorphine Jul 26, 2019

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Buprenorphine is a partial Mu-agonist and binds with higher affinity than most opioids
Pain management with opioids therefore can be difficult in patients taking buprenorphine
Ketamine is a good option for pain control in these patients
You can also consider using additional buprenorphine
Intravenous buprenorphine is dosed differently than oral formulations
Consider receptor availability - patients on high doses of buprenorphine (32mg) will have few Mu receptors available, and thus will likely not benefit from opiate pain meds of any kind

References

Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127–134.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 491: Buprenorphine for Withdrawal Jul 24, 2019

Show notes

Educational Pearls:

Buprenorphine is a semi-synthetic derivative of the opium poppy
FDA approved for the treatment of opiate use disorder and chronic pain
Benefit in emergency department use is the ceiling effect - producing less euphoria as well as respiratory depression with higher doses
It has an onset of 30-60 minutes, peak effect at 1-4 hours
Duration of action depends is dose dependent, typically 6-12 hours, but can be as long as 24-72 hours in doses over 16 mg
Use buprenorphine in those in moderate to severe opiate withdrawal
Clinical Opioid Withdrawal Scale (COWS) can be used to assess and score severity of withdrawal
A reasonable starting dose is 8mg. A second dose can be given after an hour, ranging from 8-24 mg depending on symptoms still present
Buprenorphine can induce withdrawals so someone needs to be in true withdrawals for it to provide benefit

References

https://www.mdcalc.com/cows-score-opiate-withdrawal

https://ed-bridge.org

Herring AA, Perrone J, Nelson LS. Managing Opioid Withdrawal in the Emergency Department With Buprenorphine. Ann Emerg Med. 2019 May;73(5):481-487. doi: 10.1016/j.annemergmed.2018.11.032. Epub 2019 Jan 5. Review. PubMed PMID: 30616926.

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

Podcast # 490: Canadian Syncope Rule Jul 22, 2019

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Syncope is usually benign but can be caused by serious etiologies which include: PE, certain cardiac arrhythmias, AAA, intracranial bleed/stroke
The Canadian Syncope Rule appears to identify those patients with syncope and low risk of serious outcomes
The score is based on vital signs, EKG and history
Negative scores preclude a very low risk of adverse events
A calculated score greater than 1 are considered medium risk
Scores greater than 4 are high risk
Anyone with a medium risk or higher should have their cause thoroughly investigated - which may involve admission or a shared decision making utilizing this rule if discharged

Editor's note: just remember this rule has not been externally validated… yet

References

https://www.mdcalc.com/canadian-syncope-risk-score

Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. CMAJ. 2016;188(12):E289–E298. doi:10.1503/cmaj.151469

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

Podcast # 489: Bats & Rabies Jul 18, 2019

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

The CDC recommends rabies prophylaxis if there was a direct encounter with a possibly rabid animal except...
Bats are treated differently since their bites may be very superficial and not seen/felt. All people with possible close encounters with a bat should receive rabies prophylaxis
From 1990-2007 there were 34 rabies cases associated with bats:
- 6 of these had a reported bat bite
- 15 there was a reported exposure but no reported bite
- 11 had no reported bat exposure but DNA testing revealed that the rabies came from a bat

References

Pieracci EG, Pearson CM, Wallace RM, Blanton JD, Whitehouse ER, Ma X, Stauffer K, Chipman RB, Olson V. Vital Signs: Trends in Human Rabies Deaths and Exposures - United States, 1938-2018. MMWR Morb Mortal Wkly Rep. 2019 Jun 14;68(23):524-528. doi: 10.15585/mmwr.mm6823e1. PubMed PMID: 31194721; PubMed Central PMCID: PMC6613553.

https://www.cdc.gov/rabies/specific_groups/doctors/index.html

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

Podcast # 488: Dalbavancin Jul 15, 2019

Show notes

Contributor: Nick Hatch, MD

Educational Pearls:

Dalbavancin (Dalvance®) is an antibiotic that can be used for skin and soft tissue infections, providing MRSA coverage
It cannot be used in other infections or sepsis
Dalbavancin may be appealing as a single dose lasts about 2 weeks
Expense is currently a large barrier to use
Patients with a vancomycin allergy will likely be allergic to Dalbavancin as the two are related

References

Patel M, Smalley S, Dubrovskaya Y, Siegfried J, Caspers C, Pham V, Press RA, Papadopoulos J. Dalbavancin Use in the Emergency Department Setting. Ann Pharmacother. 2019 Jun 3;:1060028019855159. doi: 10.1177/1060028019855159. [Epub ahead of print] PubMed PMID: 31155916.

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

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