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 # 467: Cauda Equina Syndrome May 09, 2019

Show notes

Author: Erik Verzemnieks, MD

Educational Pearls:

Cauda equina syndrome is caused by the compression of the nerve roots that extend beyond the termination of the spinal cord
Trauma, infection, hematoma, disc rupture/herniation can cause this - basically anything that can cause pressure and fill space
Symptoms can include saddle anesthesia, lower extremity pain, numbness, incontinence, and constipation
Post-void residual that is abnormally high may be an indicator
MRI is diagnostic modality of choice
Emergent surgical decompression is treatment

References

Jalloh I, Minhas P. Delays in the treatment of cauda equina syndrome due to its variable clinical features in patients presenting to the emergency department. Emerg Med J. 2007 Jan;24(1):33-4. doi: 10.1136/emj.2006.038182. PubMed PMID: 17183040; PubMed Central PMCID: PMC2658150.

Podcast # 466: Subacute Sclerosing Panencephalitis May 06, 2019

Show notes

Author: Nicholas Hatch, MD

Educational Pearls:

Measles has a period of infectivity starts before the appearance of the characteristic rash, up to 4-5 days
A devastating consequence of measles is Subacute Sclerosing Panencephalitis (SSPE), which manifests 7-10 years after the initial measles infection
SSPE is a central nervous system disease that has no cure and is nearly universally fatal
Educating patients on the importance of vaccination should include discussion of these long term consequences

References

Pallivathucal LB, Noymer A. Subacute sclerosing panencephalitis mortality, United States, 1979-2016: Vaccine-induced declines in SSPE deaths. Vaccine. 2018 Aug 23;36(35):5222-5225. doi: 10.1016/j.vaccine.2018.07.030. Epub 2018 Jul 26. PubMed PMID: 30057285.

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

Podcast # 465: As easy and 1, 2, 10 - Capillary Refill and Sepsis May 05, 2019

Show notes

Author: Ryan Circh, MD

Educational Pearls:

The 2019 ANDROMEDA-SHOCK trial compared using serum lactates to capillary refill assessment in septic shock patients to guide resuscitation
Capillary refill time was standardized (this is not straightforward):
- A glass microscope slide was pressed on the ventral side of the right index finger
- Pressure was increased until the skin was blanched
- This pressure was sustained for another 10 seconds
- After pressure was removed, the time to return to normal skin color was timed
- Greater than three seconds was considered abnormal.
No difference between the two groups for mortality at 28-days

Editor's note: lactates have become so ingrained in our practice it will be tough to change habits but this is an excellent quiver for those of us that hate the over reliance on this lab value alone, despite some of the limitations of the study.

References

Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654–664. doi:10.1001/jama.2019.0071

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

Podcast # 464: Narcan't? May 02, 2019

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

A problem of take-home-naloxone is the administration of it by an able-bodied bystander
Australian study looked at consecutive opioid overdose deaths in a single year to identify characteristics of overdose and potential for bystander administered naloxone
Of the 235 fatal heroin overdoses reviewed, 83% were alone with only 17% (38 cases) having another person present
Half of those in the presence of others had a bystander that was not impaired
Take-home-naloxone needs a competent person to administer it. Make sure to review this along with other harm reduction strategies when prescribing/dispensing it to patients

References

Stam NC, Gerostamoulos D, Smith K, Pilgrim JL, Drummer OH. Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia. Clin Toxicol (Phila). 2019 May;57(5):325-330. doi: 10.1080/15563650.2018.1529319. Epub 2018 Nov 17. PubMed PMID: 30451007.

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

Podcast # 463: Buproprion Overdose Apr 30, 2019

Show notes

Author: Erik Verzemnieks, MD

Educational Pearls:

Buproprion is used as an antidepressant and for smoking cessation
Severe buproprion overdoses can cause seizures and lead to cardiac dysrhythmias
Benzodiazepines are treatment of choice for seizures
Bicarbonate and Interlipid are also possible treatment options with less evidence

References

Stall N, Godwin J, Juurlink D. Bupropion abuse and overdose. CMAJ. 2014 Sep 16;186(13):1015. doi: 10.1503/cmaj.131534. Epub 2014 Apr 28. PubMed PMID: 24778361; PubMed Central PMCID: PMC4162783.

Balit CR, Lynch CN, Isbister GK. Bupropion poisoning: a case series. Med J Aust. 2003 Jan 20;178(2):61-3. PubMed PMID: 12526723.

Bruccoleri RE, Burns MM. A Literature Review of the Use of Sodium Bicarbonate for the Treatment of QRS Widening. J Med Toxicol. 2016 Mar;12(1):121-9. doi: 10.1007/s13181-015-0483-y. Review. PubMed PMID: 26159649; PubMed Central PMCID: PMC4781799.

Podcast # 462: Death after OD Apr 27, 2019

Show notes

Author: Don Stader, MD

Educational Pearls:

10% of patients seen in the emergency department for opioid overdose patients will die within a year
Half of these overdoses will occur in the next month
This mortality rate is higher than patients with STEMI, of which 7% will die within one year
Take-home naloxone, as well as medication assisted treatment like buprenorphine can save lives

References

Olfson M, Crystal S, Wall M, Wang S, Liu SM, Blanco C. Causes of Death After Nonfatal Opioid Overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-827. doi: 10.1001/jamapsychiatry.2018.1471. PubMed PMID: 29926090; PubMed Central PMCID: PMC6143082.

Olfson M, Wall M, Wang S, Crystal S, Blanco C. Risks of fatal opioid overdose during the first year following nonfatal overdose.Drug Alcohol Depend. 2018 Sep 1;190:112-119. doi: 10.1016/j.drugalcdep.2018.06.004. Epub 2018 Jul 4. PubMed PMID: 30005310.

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

Podcast # 461: Breath Stacking Apr 24, 2019

Show notes

Author: Gretchen Hinson, MD

Educational Pearls:

Breath stacking occurs when a patient is unable to expire fully before another inspiration
In intubated/ventilated patients, this is because adequate time has not passed before exhalation
Asthmatics are susceptible due to the prolonged expiratory phase
Complications can include reduction in cardiac preload and cardiovascular collapse
Pursed-lip breathing can help in the spontaneously breathing patient
Intubation may be required when patients present with status asthmaticus and breath stacking

References

Phipps P, Garrard CS. The pulmonary physician in critical care . 12: Acute severe asthma in the intensive care unit. Thorax. 2003 Jan;58(1):81-8. Review. PubMed PMID: 12511728; PubMed Central PMCID: PMC1746457.

Pohlman MC, McCallister KE, Schweickert WD, Pohlman AS, Nigos CP, Krishnan JA, Charbeneau JT, Gehlbach BK, Kress JP, Hall JB. Excessive tidal volume from breath stacking during lung-protective ventilation for acute lung injury. Crit Care Med. 2008 Nov;36(11):3019-23. doi: 10.1097/CCM.0b013e31818b308b. PubMed PMID: 18824913.

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

Podcast # 460: Hunting for PE in Syncope Apr 22, 2019

Show notes

Author: Michael Hunt, MD

Educational Pearls:

Most causes of syncope are benign
Pulmonary embolism can result in syncope and is life threatening
A recent study of Canadian and US ED patients with syncope showed that 0.4% of patients had a PE at 30 day follow-up
PE should always be considered in cases of syncope but overall is a rare cause

Editor's note: this study puts to rest a previous study from 2016 that reported a rate of PE in syncope as high as 1 in 6 in patients admitted to syncope - which was met with much skepticism based on clinical practice.

References

Roncon L, Zuin M, Casazza F, Becattini C, Bilato C, Zonzin P. Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism. Eur J Intern Med. 2018 Aug;54:27-33. doi: 10.1016/j.ejim.2018.04.004. Epub 2018 Apr 11. PubMed PMID: 29655808.

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

Podcast # 459 Clonidine Ingestion Apr 20, 2019

Show notes

Author: Julian Orenstein, MD

Educational Pearls:

Severe clonidine ingestion can present as a fluctuating mental status between typically accompanied by changes in vital signs (hypotension/bradycardia)
Respiratory depression requiring intubation is not uncommon

References

Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia and central nervous system depression, but not severe toxicity. Clin Toxicol (Phila). 2017 Mar;55(3):187-192. doi: 10.1080/15563650.2016.1277234. Epub 2017 Jan 20. PubMed PMID: 28107093.

Spiller HA, Klein-Schwartz W, Colvin JM, Villalobos D, Johnson PB, Anderson DL. Toxic clonidine ingestion in children. J Pediatr. 2005 Feb;146(2):263-6. PubMed PMID: 15689921.

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

Podcast # 458: A Tylenol a Day Keeps the Delirium Away? Apr 17, 2019

Show notes

Author: Nick Hatch, MD

Educational Pearls:

A recent study investigated the effect of scheduled IV acetaminophen on the incidence of delirium in post-CABG patients in the ICU
The use of scheduled IV acetaminophen reduced the rate of delirium in these patients compared to placebo
This may be due to the analgesic effect of acetaminophen and/or less requirement on other deliriogenic medications (opiates)

References

Subramaniam B, Shankar P, Shaefi S, Mueller A, O'Gara B, Banner-Goodspeed V, Gallagher J, Gasangwa D, Patxot M, Packiasabapathy S, Mathur P, Eikermann M, Talmor D, Marcantonio ER. Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial. JAMA. 2019 Feb 19;321(7):686-696. doi: 10.1001/jama.2019.0234. PubMed PMID: 30778597.

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

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