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 # 487: Hunting for Epiglottitis Jul 10, 2019

Show notes

Contributor: Michael Hunt, MD

Educational Pearls:

Due to the efficacy of vaccination, epiglottitis is now more common in adults than children
Risk factors include smoking and other immunocompromising co-morbidities, such as diabetes
Epiglottitis can present with sore throat and fever, with potential rapid progression to respiratory distress and stridor
Diagnosis can include x-ray to look for the "thumbprint sign," nasofiberoptics, and/or CT
Antibiotics are mainstay of treatment but severe cases may need establishment of a definitive airway, typically done with fiberoptics in the operating room due to the potential to irritate the epiglottitis with traditional laryngoscopy

References

Li RM, Kiemeney M. Infections of the Neck. Emerg Med Clin North Am. 2019 Feb;37(1):95-107. doi: 10.1016/j.emc.2018.09.003. Review. PubMed PMID: 30454783.

Tsai YT, Huang EI, Chang GH, Tsai MS, Hsu CM, Yang YH, Lin MH, Liu CY, Li HY. Risk of acute epiglottitis in patients with preexisting diabetes mellitus: A population-based case-control study. PLoS One. 2018;13(6):e0199036. doi: 10.1371/journal.pone.0199036. eCollection 2018. PubMed PMID: 29889887; PubMed Central PMCID: PMC5995441.

Guerra AM, Waseem M. Epiglottitis. [Updated 2018 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430960/

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

Podcast # 486: Morel Mushrooms Jul 08, 2019

Show notes

Contributor: Nick Hatch, MD

Educational Pearls:

True morel mushrooms are commonly foraged
The false morel mushroom (Gyromitra esculenta) looks similar to the true morel, but is toxic
False morel mushroom toxicity can cause gastrointestinal symptoms as well as liver failure, rhabdomyolysis, and seizures
Seizures can be refractory to benzodiazepine therapy and may require use of vitamin B6 and propofol

References

Horowitz KM, Horowitz BZ. Gyromitra Mushroom Toxicity. [Updated 2019 May 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470580/

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

Podcast # 485: Cerebellar Stroke Jul 06, 2019

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Cerebellar strokes make up a disproportionate number of missed or delayed diagnosis for stroke likely due to the subtle nature of the presentation
Cerebellar strokes can present with vomiting, dizziness, and ataxia.
Unlike anterior circulation stroke, exam findings in a cerebellar stroke are ipsilateral to the lesion
On neuro exam, findings may include:
- Dysmetria: lack of coordination with overshooting/undershooting intended position of limb
- Dysdiadochokinesia: difficulty with rapid alternating movements
- Ataxia
- Nystagmus
Consider a cerebellar stroke in patients presenting with vomiting and dizziness without an alternative diagnosis

References

Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol. 2008 Oct;7(10):951-64. doi: 10.1016/S1474-4422(08)70216-3. Review. PubMed PMID: 18848314.

Datar S, Rabinstein AA. Cerebellar infarction. Neurol Clin. 2014 Nov;32(4):979-91. doi: 10.1016/j.ncl.2014.07.007. Epub 2014 Sep 13. Review. PubMed PMID: 25439292.

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

Podcast # 484: Elevated ICP Jul 04, 2019

Show notes

Contributor: Charleen Gnisci, PharmD

Educational Pearls:

Causes of increased intracranial pressure may include intracranial hemorrhage, malignancy, and trauma.
While definite treatment is to remove the offending cause, there are emergency medicine
Non-pharmacologic methods include elevating head of bed and removing noxious stimuli
Pharmacologic options include mannitol and hypertonic saline
Hypertonic saline is best delivered through a central line but not required
Both these agents benefit from adequate renal function
Before using mannitol, be sure to inspect the bag to ensure that it has not precipitated. If it has, try warming the bag before administration.

References

https://pulmccm.org/critical-care-review/hyperosmolar-therapy-for-increased-intracranial-pressure-review-nejm/

Burgess S, Abu-Laban RB, Slavik RS, Vu EN, Zed PJ. A Systematic Review of Randomized Controlled Trials Comparing Hypertonic Sodium Solutions and Mannitol for Traumatic Brain Injury: Implications for Emergency Department Management. Ann Pharmacother. 2016 Apr;50(4):291-300. doi: 10.1177/1060028016628893. Epub 2016 Jan 29. Review. PubMed PMID: 26825644.

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

Podcast # 483: Dual Antiplatelet Therapy in TIA Jun 28, 2019

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Antiplatelets include aspirin and clopidogrel, and are generally used for arterial clotting (MI, stroke)
Anticoagulants such as coumadin, Xarelto, Eliquis are generally used for venous clotting (DVT/PE)
Growing data suggests that dual antiplatelet therapy (aspirin+clopidogrel) is superior to aspirin alone in reducing stroke for diagnosed with TIA

References:

Kheiri B, Osman M, Abdalla A, Haykal T, Swaid B, Ahmed S, Chahine A, Hassan M, Bachuwa G, Al Qasmi M, Bhatt DL. Clopidogrel and aspirin after ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis of randomized clinical trials. J Thromb Thrombolysis. 2019 Feb;47(2):233-247. doi: 10.1007/s11239-018-1786-z. PubMed PMID: 30511260.

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

Podcast # 482: Tetracyclines and Hyperpigmentation Jun 26, 2019

Show notes

Contributor: Michael Hunt, MD

Educational Pearls:

Tetracycline antibiotics such as minocycline can cause greyish hyperpigmentation
This hyperpigmentation can sometimes be reversible but not always
Minocycline has been used for its effects in autoimmune and neurological diseases, where it is often taken chronically, which can lead to increased pigmentation

References

La Placa M, Infusino SD, Balestri R, Vincenzi C. Minocycline-Induced Blue-Gray Discoloration. Skin Appendage Disord. 2017 Aug;3(3):161-162. doi: 10.1159/000469712. Epub 2017 Apr 22. PubMed PMID: 28879193; PubMed Central PMCID: PMC5582477.

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

Podcast # 481: Medical Errors and Cognitive Bias Jun 21, 2019

Show notes

Contributor: Peter Bakes, MD

Educational Pearls:

While there are many different types of medical error, one of the most common errors in emergency medicine is failure to diagnose
Systematic error in thinking that negatively affects judgement
Medical errors are often driven by cognitive biases, which include anchoring, attribution, and availability
Anchoring bias occurs when early information leads to premature closure on a single diagnosis. There is subsequent failure to consider alternative diagnoses, even in the face of conflicting new data and test results.
Attribution bias occurs when assumptions about personal and medical characteristics are made about a specific group of people.
Availability bias occurs when recent experiences drive providers to over or under consider diagnoses.

References

Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003 Jan;41(1):110-20. doi: 10.1067/mem.2003.22. PubMed PMID: 12514691.

Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005 Jan 18;142(2):115-20. doi: 10.7326/0003-4819-142-2-200501180-00010. PubMed PMID: 15657159.

https://www.nuemblog.com/blog/cognitive-bias

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

Podcast # 480: Inhalant Abuse Jun 19, 2019

Show notes

Author: Sam Killian, MD

Educational Pearls:

Abuse occurs by breathing in volatile substances such as solvents, glues, paints, butane, and propane
Inhalants are generally depressants
Estimated that 100-125 people die every year in the US from acute inhalant abuse.
Short-term effects include memory impairment, slurred speech, diplopia, seizures, and cardiac arrhythmias
Long term effects include renal dysfunction, neuropathy, blindness and cognitive blunting
Evaluation includes a detailed lung exam, cardiac monitoring, and assessments of oxygenation and renal function
Treatment is generally supportive.

References

Lipari RN. Understanding Adolescent Inhalant Use. 2013;. Review. PubMed PMID: 28722849.

Howard MO, Bowen SE, Garland EL, Perron BE, Vaughn MG. Inhalant use and inhalant use disorders in the United States. Addict Sci Clin Pract.2011 Jul;6(1):18-31. Review. PubMed PMID: 22003419; PubMed Central PMCID: PMC3188822.

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

Podcast # 479: Clots and Pregnancy Jun 17, 2019

Show notes

Author: Nick Hatch, MD

Educational Pearls:

Pregnancy is a hypercoagulable state, which predisposes women to venous thromboembolism, but also elevates levels of circulating d-dimer
A recent study evaluated the YEARS protocol in combination of adjusted d-dimer cutoffs in pregnant women to evaluate for DVT and PE
Using this protocol, only 1 DVT was missed. No PE's were missed.
This protocol has growing evidence as an option in pregnant women in whom you must rule out a DVT/PE but more validating studies are likely necessary

References

van der Pol LM, Tromeur C, Bistervels IM, Ni Ainle F, van Bemmel T, Bertoletti L, Couturaud F, van Dooren YPA, Elias A, Faber LM, Hofstee HMA, van der Hulle T, Kruip MJHA, Maignan M, Mairuhu ATA, Middeldorp S, Nijkeuter M, Roy PM, Sanchez O, Schmidt J, Ten Wolde M, Klok FA, Huisman MV. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 2019 Mar 21;380(12):1139-1149. doi: 10.1056/NEJMoa1813865. PubMed PMID: 30893534.

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

Podcast # 478: Psychedelics and Depression Jun 14, 2019

Show notes

Author: Chris Holmes, MD

Educational Pearls:

Hallucinogenic drugs have been in use since ancient times for both medical and recreational purposes
Ayahausca is an ancient psychedelic with origins in Bolivia that causes intense vomiting followed by a psychedelic experience
This and other hallucinogens are gaining gaining interest for their use in depression with some startling positive initial results

References

https://www.nationalgeographic.com/culture/2019/05/ancient-hallucinogens-oldest-ayahuasca-found-shaman-pouch/

Carhart-Harris RL et. al. Psilocybin with psychological support for treatment-resistant depression: six-month follow-up. Psychopharmacology (Berl). 2018 Feb;235(2):399-408. doi: 10.1007/s00213-017-4771-x. Epub 2017 Nov 8. PubMed PMID: 29119217; PubMed Central PMCID: PMC5813086.

Palhano-Fontes F et. al. Rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression: a randomized placebo-controlled trial. Psychol Med. 2019 Mar;49(4):655-663. doi: 10.1017/S0033291718001356. Epub 2018 Jun 15. PubMed PMID: 29903051; PubMed Central PMCID: PMC6378413.

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

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