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 # 477: Postpolypectomy Electrocoagulation Syndrome Jun 12, 2019

Show notes

Author: Nick Hatch, MD

Educational Pearls:

Postpolypectomy electrocoagulation syndrome (PES) is a rare complication of polypectomy and electrocautery during colonoscopy
Occurs when cautery causes transmural thickening from a contact burn
Patients can present as if they have peritonitis, with guarding, leukocytosis, fever, etc.
CT is the imaging of choice mainly to evaluate for bowel perforation as PES may not be seen on imaging
Treatment is often with antibiotics and supportive care - in severe cases, hospitalization may be required.

References

Benson BC, Myers JJ, Laczek JT. Postpolypectomy electrocoagulation syndrome: a mimicker of colonic perforation. Case Rep Emerg Med. 2013;2013:687931. doi: 10.1155/2013/687931. Epub 2013 Jul 15. PubMed PMID: 23956889; PubMed Central PMCID: PMC3728495.

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

Podcast # 476: Evidence for Patient Satisfaction Jun 05, 2019

Show notes

Author: Dylan Luyten, MD

Educational Pearls:

Actual wait times are weakly correlated to patient satisfaction but the difference between perceived/expected wait times and actual wait times is strongly correlated
Having others in the room or with the patient while they wait also has a positive effect
Under-promising and over-delivering can result in better patient experience
Managing up others and services provided also is demonstrated to improve satisfaction
Perceived time with health care members (physicians, APPs, nurses, etc) also is supported to improve satisfaction
Sitting with patients increases the perception of time

References

Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say?. Acad Emerg Med. 2000 Jun;7(6):695-709. Review. PubMed PMID: 10905652.

Sonis JD, Aaronson EL, Lee RY, Philpotts LL, White BA. Emergency Department Patient Experience: A Systematic Review of the Literature. J Patient Exp. 2017;5(2):101–106. doi:10.1177/2374373517731359

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

Podcast # 475: Orthostatic Vital Signs and Syncope Jun 02, 2019

Show notes

Author: Michael Hunt, MD

Educational Pearls:

A recent study evaluated the relationship between abnormal orthostatic vital signs and serious outcomes within 30 days in patients over 60 presenting to the ED with syncope
Of the roughly 2000 patients enrolled, about ⅓ had abnormal orthostatic vital signs
There was no statistically significance between orthostatic vital signs and serious outcomes in 30 days

Editor's note: study used a composite end-point of multiple serious outcomes

References

White JL, Hollander JE, Chang AM, Nishijima DK, Lin AL, Su E, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Clark CL, Diercks DB, Nicks BA, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study. Am J Emerg Med. 2019 Mar 25;. doi: 10.1016/j.ajem.2019.03.036. [Epub ahead of print] PubMed PMID: 30928476.

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

Podcast # 474: Obesity Hypoventilation Syndrome May 29, 2019

Show notes

Author: Peter Bakes, MD

Educational Pearls:

The differential diagnosis for pedal edema includes issues in the heart, kidney, and liver
Obesity hypoventilation syndrome (OHS) is an important and common cause of right heart failure. Nighttime hypoventilation leads to pulmonary hypertension, causing right heart strain followed by right heart failure
OHS criteria includes obesity, sleep disordered breathing, and alveolar hypoventilation (PaCO2 > 45 mmHg)
The causes of OHS are multifactorial, and include mechanical problems with breathing and hormonal changes

References

Balachandran JS, Masa JF, Mokhlesi B. Obesity Hypoventilation Syndrome Epidemiology and Diagnosis. Sleep Med Clin. 2014;9(3):341–347. doi:10.1016/j.jsmc.2014.05.007

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

Podcast # 473: Direct to Consumer Antibiotics May 24, 2019

Show notes

Author: Sam Killian, MD

Educational Pearls:

A recent study in Pediatrics compared the rates of antibiotic prescriptions for acute respiratory infections (ARIs) between direct to consumer (DTC) telemedicine, urgent care, and primary care providers
Among the nearly 530,000 visits studied, the rate of antibiotic prescription was 52%, 42% and 31% for telemedicine, urgent care, and primary care providers, respectively
Nearly 4/10 antibiotic prescriptions from telemedicine visits were not indicated based on antibiotics guideline recommendations

References

Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics. 2019 May;143(5). doi: 10.1542/peds.2018-2491. Epub 2019 Apr 8. PubMed PMID: 30962253.

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

Podcast # 472: SMART Crystalloids May 23, 2019

Show notes

Author: Gretchen Hinson, MD

Educational Pearls:

In most healthcare settings, normal saline (NS) has become ubiquitous as an intravenous fluid despite some potential drawbacks
Compared to normal saline, a balanced crystalloid (either lactated Ringer's or Plasma-Lyte) was associated with a lower composite endpoint of mortality, renal replacement therapy, and renal injury in SMART (Isotonic Solutions and Major Adverse Renal Events Trial)
Balanced crystalloids such as lactate Ringer's may be preferable in more critically ill populations

References

Yau YW, Kuan WS. Choice of crystalloids in sepsis: a conundrum waiting to be solved. Ann Transl Med. 2016;4(6):121. doi:10.21037/atm.2016.02.09

Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829–839. doi:10.1056/NEJMoa1711584

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

Podcast # 471: Cyclic Vomiting May 21, 2019

Show notes

Author: Don Stader, MD

Educational Pearls:

Cyclic vomiting syndrome (CVS) is different than cannabis hyperemesis syndrome (CHS). It is important to differentiate the two.
CHS is thought to be caused by activation of THC receptors in the gut
CVS is associated with migraines and therefore responds to similar medications
Olanzapine (Zyprexa) is an alternative to haloperidol (Haldol)
Amitriptyline, as well as anti-epileptics can be used to prevent CVS
Opioids worsen CVS

References

Lapoint J, Meyer S, Yu CK, Koenig KL, Lev R, Thihalolipavan S, Staats K, Kahn CA.Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline. West J Emerg Med. 2018 Mar;19(2):380-386. doi: 10.5811/westjem.2017.11.36368. Epub 2017 Nov 8. PubMed PMID: 29560069; PubMed Central PMCID: PMC5851514.

Boles RG, Lovett-Barr MR, Preston A, Li BU, Adams K. Treatment of cyclic vomiting syndrome with co-enzyme Q10 and amitriptyline, a retrospective study. BMC Neurol. 2010;10:10. Epub 2010 Jan 28.

Hikita T, Kodama H, Kaneko S, Amakata K, Ogita K, Mochizuki D, Kaga F, Nakamoto N, Fujii Y, Kikuchi A. Sumatriptan as a treatment for cyclic vomiting syndrome: a clinical trial. Cephalalgia. 2011;31(4):504. Epub 2010 Dec 8.

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

Podcast # 470: Zofran and Pregnancy May 17, 2019

Show notes

Author: Jared Scott, MD

Educational Pearls:

Ondansetron (Zofran) is one of the latest drugs that has had concerns raised about side effects, particularly in pregnancy
2018 study probed two birth defect databases to assess increases in 51 major birth defects with increased exposure to ondansetron
Only two of the 51 had even a modest increase, which is unclear in causation (cleft palate and renal agenesis)
When administering ondansetron (or any drug) to pregnant women, be able to discuss any potential risks for an informed decision by the patient

Editor's note: in this study, adjusted odds ratios for risk of birth defects from exposure to ondansetron were: cleft palate 1.6 (95% CI 1.1-2.3) and renal agenesis 1.8 (95% CI 1.1-3.0)

References

Parker SE, Van Bennekom C, Anderka M, Mitchell AA. Ondansetron for Treatment of Nausea and Vomiting of Pregnancy and the Risk of Specific Birth Defects. Obstet Gynecol. 2018 Aug;132(2):385-394. doi: 10.1097/AOG.0000000000002679. PubMed PMID: 29995744.

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

Podcast # 469: Go PO May 16, 2019

Show notes

Author: Dave Rosenberg, MD

Educational Pearls:

Nothing by mouth (NPO) status routinely used before surgery to reduce the theoretical risk of aspiration
However, surgery poses a large physiological stress. Calories and fluid are needed to overcome stresses like these
Patients who drank 1/2 strength Gatorade up to 2 hours before surgery did better than those who did not

References

Alyssa Cheng-Cheng Zhu, Aalok Agarwala, Xiaodong Bao. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clinics in Colon and Rectal Surgery 2019; 32(02): 114-120. DOI: 10.1055/s-0038-1676476

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

Podcast # 468: Typhlitis May 14, 2019

Show notes

Educational Pearls:

Tiflitis refers to the presence of enterocolitis in the setting of neutropenia - also known as neutropenic enterocolitis
Commonly a result of chemotherapy for hematologic malignancies.
The infection is usually polymicrobial/fungal and can lead to septic shock
Usually presents with fever, abdominal pain, with associated GI complaints
Workup includes CBC for the ANC (usually
Treatment typically with broad-spectrum antibiotics with or without anti-fungal agents
Mortality can be as high as 50%

References

Cloutier RL. Neutropenic enterocolitis. Emerg Med Clin North Am. 2009 Aug;27(3):415-22. doi: 10.1016/j.emc.2009.04.002. PubMed PMID: 19646645.

Rodrigues FG, Dasilva G, Wexner SD. Neutropenic enterocolitis. World J Gastroenterol.2017 Jan 7;23(1):42-47. doi: 10.3748/wjg.v23.i1.42. Review. PubMed PMID: 28104979; PubMed Central PMCID: PMC5221285.

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

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