Emergency Medical Minute

Latest Episodes:

Episode 971: Calcium Pretreatment for Diltiazem in AFib with RVR Aug 25, 2025

Show notes

Contributor: Taylor Lynch, MD

Educational Pearls:

What is atrial fibrillation with rapid ventricular response (AFib with RVR) and how does it differ from atrial fibrillation (AFib)?

AFib is an abnormal heart rhythm in which the heart has disorganized atrial electrical activity. This causes the atria to quiver with only select signals being conducted through the Atrioventricular (AV) Node to reach the ventricles and result in ventricular contraction.
Often described as "irregularly irregular", a patient's EKG will present with no discernible P-waves, and irregular R-R intervals.
AFib with RVR is distinguished from AFib when the patient's ventricular rate is greater than 100-110 beats per minute in AFib with RVR.

What is the treatment for AFib with RVR?

Diltiazem is considered one of the first line therapeutic agents in the treatment of AFib with RVR.
Diltiazem inhibits L-Type calcium channels in the AV Node, reducing the amount of signals conducted to the ventricles, thus reducing the ventricular rate.

Why pretreat patients receiving Diltiazem for AFib with RVR with calcium?

While diltiazem inhibits cardiac calcium channels, it may also cause peripheral vasodilation, resulting in diltiazem-induced hypotension.
A recent study found that this hypotension can be blunted by pretreating with 1-2g IV Calcium Chloride (IV Calcium Gluconate can be used in the ED).
Calcium is thought to peripherally stabilize the vascular smooth muscle, preventing vasodilation without impacting the desired calcium channel blocker action at the AV node.

Key takeaways?

In combination with slower pushes of diltiazem for patients in AFib with RVR (AFib with ventricular rate >100-110 bpm) with borderline low blood pressures, 1-2 g of IV Calcium Gluconate can combat diltiazem induced hypotension peripherally without negating the cardiac effect of diltiazem to reduce the heart rate.

References

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193
Az A, Sogut O, Dogan Y, et al. Reducing diltiazem-related hypotension in atrial fibrillation: Role of pretreatment intravenous calcium. Am J Emerg Med. 2025;88:23-28. doi:10.1016/j.ajem.2024.11.033

Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan and Jorge Chalit, OMS4

Get your tickets to Tox Talks Event, Sept 11, 2025: https://emergencymedicalminute.org/events-2/

Donate: https://emergencymedicalminute.org/donate/

Episode 970: Fever Management Aug 22, 2025

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Recorded March 2025

What is the best treatment for a fever? Tylenol? Ibuprofen? Combined? Alternating the two?

The journal Pediatrics aimed to answer this question with a meta-analysis of 31 randomized controlled trials including 5,009 febrile children.
Results showed that both combined and alternating acetaminophen/ibuprofen regimens were significantly more effective at reducing fever at 4 and 6 hours compared with acetaminophen alone, with numbers needed to treat (NNT) of 3 and 4, respectively.
High-dose ibuprofen alone also offered modest benefit (NNT 8).

What dose should I use?

Oral acetaminophen
- 10 to 15 mg/kg
- Every 4–6 hours as needed
- Do not exceed 75 mg/kg/day (or 4,000 mg/day maximum for older/larger kids)
Oral ibuprofen
- 5 to 10 mg/kg
- Every 6–8 hours as needed
- Do not exceed 40 mg/kg/day (or 2,400 mg/day maximum for older/larger kids)

References

De la Cruz-Mena JE, Veroniki AA, Acosta-Reyes J, Estupiñán-Bohorquez A, Ibarra JA, Pana MC, Sierra JM, Florez ID. Short-term Dual Therapy or Mono Therapy With Acetaminophen and Ibuprofen for Fever: A Network Meta-Analysis. Pediatrics. 2024 Oct 1;154(4):e2023065390. doi: 10.1542/peds.2023-065390. PMID: 39318339.

Summarized by Jeffrey Olson, MS4 | Edited by Jeffrey Olson and Jorge Chalit, OMS4

Get your tickets to Tox Talks Event, Sept 11, 2025: https://emergencymedicalminute.org/events-2/

Donate: https://emergencymedicalminute.org/donate/

Episode 969: Shoulder Reduction Aug 11, 2025

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

There are many techniques for reducing a shoulder dislocation
A recent study discussed a new variation of closed reduction technique: wrist-clamping shoulder-lifting
- The patient is in a sitting position
- The provider holds the wrist of the injured arm with both hands and slowly rotates the arm to 90 degrees of abduction and 60 degrees of external rotation
- After this traction, the arm is slowly moved to 45 degrees of abduction and 60 degrees of external rotation
- The provider then secures the patient's wrist between the provider's knees and places their hand on the axilla to gently lift the shoulder upward for successful reduction
There were 36 patients with shoulder dislocations in this study, and all 36 dislocations were successfully reduced with this technique
- There were no neurovascular complications or fractures
- No sedation or medication was required
- All procedures were performed by a single provider without assistance

References

Dai W, Liu L, Zong S, Zhou Y, Zheng J, Li X. An original closed reduction technique for acute shoulder dislocation: the wrist-clamping and shoulder-lifting. Int J Emerg Med. 2025 Mar 26;18(1):60. doi: 10.1186/s12245-025-00866-8. PMID: 40140973; PMCID: PMC11948627.

Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Episode 968: Heavy Metals Aug 04, 2025

Show notes

Contributor: Megan Hurley MD Educational Pearls:

Acute toxicity of heavy metals:

Gastrointestinal upset is the most common presentation

Chronic toxicity of heavy metals:

Symptoms depend on the metal ingested
Increased risk of cancer
Altered mentation
Developmental delays (in children)
Kidney failure

Four heavy metals that are tested for in a general panel and their sources:

Lead
- Old paint (homes built before 1977) or some older toys
- Pipes of older homes or those with corrosive agents
- May obtain testing kits from home improvement stores to test water supply
Mercury
- Previously in thermometers, although much less common now
- Compact fluorescent lightbulbs, LCD screens, and some batteries
- Large predatory fish like tuna, swordfish, dolphins, and shark
Arsenic sources
- Most commonly found in pesticides
- Contaminated groundwater (especially private wells)
Cadmiun sources
- Most commonly found in tobacco smoke
- Batteries
- Metal plating and welding
Additional heavy metals that require specific testing
- Chromium, Nickel, & Thallium
- Thallium is found in rodenticides, pesticides, and fireworks

Management of heavy metal toxicity depends on the intoxicant

Generally, chelation therapy is used for acute and severe cases
Arsenic: dimercaprol or DMSA
Mercury: DMPS (chronic or mild) or DMSA (severe)
Lead: succimer is first line, followed by dimercaprol or EDTA

References

Baker BA, Cassano VA, Murray C; ACOEM Task Force on Arsenic Exposure. Arsenic Exposure, Assessment, Toxicity, Diagnosis, and Management: Guidance for Occupational and Environmental Physicians. J Occup Environ Med. 2018;60(12):e634-e639. doi:10.1097/JOM.0000000000001485
Balali-Mood M, Naseri K, Tahergorabi Z, Khazdair MR, Sadeghi M. Toxic Mechanisms of Five Heavy Metals: Mercury, Lead, Chromium, Cadmium, and Arsenic. Front Pharmacol. 2021;12:643972. Published 2021 Apr 13. doi:10.3389/fphar.2021.643972
Kinally C, Fuller R, Larsen B, Hu H, Lanphear B. A review of lead exposure source attributional studies. Sci Total Environ. 2025;990:179838. doi:10.1016/j.scitotenv.2025.179838
Jannetto PJ, Cowl CT. Elementary Overview of Heavy Metals. Clin Chem. 2023;69(4):336-349. doi:10.1093/clinchem/hvad022
Järup L. Hazards of heavy metal contamination. Br Med Bull. 2003;68:167-182. doi:10.1093/bmb/ldg032
Zhang H, Reynolds M. Cadmium exposure in living organisms: A short review. Sci Total Environ. 2019;678:761-767. doi:10.1016/j.scitotenv.2019.04.395

Summarized & Edited by Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Episode 967: Dilutional Hyponatremia Jul 28, 2025

Show notes

Contributor: Taylor Lynch, MD

Educational Pearls:

Dilutional Hyponatremia:

Occurs when there is an excess of free water relative to sodium in the body.
Causes a falsely low sodium concentration without a true change in total body sodium.

Commonly seen in DKA:

Hyperglycemia raises plasma osmolality.
Water shifts from the intracellular to extracellular space.
This dilutes serum sodium, creating apparent hyponatremia.

Corrected sodium calculation:

Use tools like MDCALC, or apply this formula:

Add 1.6 mEq/L to the measured sodium for every 100 mg/dL increase in glucose above 100.

Clinical relevance:

Considering corrected sodium in DKA is crucial, as the lab value may not be reflective of actual sodium depletion.
True severe hyponatremia can lead to complications like seizures
- May require treatment with hypertonic saline.

References:

Fulop M. Acid–base problems in diabetic ketoacidosis. Am J Med Sci. 2008;336(4):274-276. doi:10.1097/MAJ.0b013e318180f478
Palmer BF, Clegg DJ. Electrolyte and Acid–Base Disturbances in Patients with Diabetes Mellitus. N Engl J Med. 2015;373(6):548-559. doi:10.1056/NEJMra1503102
Spasovski G, Vanholder R, Allolio B, et al. Diagnosis and management of hyponatremia: a review. JAMA. 2014;312(24):2640–2650. doi:10.1001/jama.2014.13773

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

EMSAC 2024 Jul 26, 2025

Show notes

Contributors:

Col. (Dr.) Stacy Shackelford Dr. Sean Keenan Paramedic Alan Moreland Dr. Chris Tems Kara Napolitano

From military-inspired trauma protocols to behavioral health alternatives and cardiac resuscitation, EMS is evolving fast. Our Medical Minutes from EMSAC highlight the growing need for prehospital providers to think critically, act quickly, and adapt to new approaches in trauma, crisis response, and patient advocacy.

Educational Pearls:

What was covered & recorded at EMSAC 2024 by EMM?

Col. (Dr.) Stacy Shackelford, U.S. Air Force trauma surgeon and Director of the Joint Trauma System, emphasized the critical importance of early hemorrhage control and timely transfusions in prehospital trauma care. She highlighted military studies showing that interventions within 30 minutes can dramatically increase survival, underscoring the value of rapid response and frontline readiness.

Dr. Sean Keenan, retired Army emergency physician and EMS doctor, introduced the concept of prolonged field care—managing critically injured patients in environments where evacuation is delayed. He discussed how this model, developed in the military, is now being taught to civilian EMS providers in rural areas.

Paramedic Alan Moreland from Denver's STAR Program (Support Team Assisted Response) explained how alternative response teams, pairing paramedics with clinical social workers, are reshaping how we respond to behavioral health emergencies, reducing reliance on police or ambulance transport and focusing on trauma-informed care.

Dr. Chris Tems, an emergency physician working with ECMO (extracorporeal membrane oxygenation), shared data on using ECMO for refractory cardiac arrest. With a survival rate of 87.5% in select emergency department cases, he highlighted ECMO's growing role in cardiac resuscitation for patients not responding to CPR.

Kara Napolitano, of the Laboratory to Combat Human Trafficking, outlined the role EMS plays in recognizing human trafficking. She offered key indicators to look for and encouraged providers to stay alert to the signs of exploitation, emphasizing EMS's role in early intervention.

Recorded by: Steven Fujaros, Brian Parga, & Ahmed Abdel-Hafiz Summarized by: Steven Fujaros

Episode 966: Acetaminophen Toxicity Jul 21, 2025

Show notes

Contributor: Jorge Chalit-Hernandez, OMS4

Educational Pearls:

What is the toxic dose of acetaminophen?
- 7.5 grams, in an adult. The safe daily limit is 4 grams in an adult with a normally functioning liver.
- This is equivalent to fifteen 500mg pills.
What are the symptoms of acetaminophen toxicity?
- First 24 hours, symptoms are non-specific e.g. nausea, vomiting, lack of appetite. Can also be asymptomatic.
- 24-72 hours, hepatotoxicity occurs (causing yellow skin, pruritus, abdominal pain, bleeding, and confusion)
- Fulminant liver failure at 72-96 hours
- Liver function tests (LFTs) peak at 72-96 hours.
When would you give activated charcoal?
- Within 4 hours of ingestion.
- The risk of activated charcoal is that it can be very dangerous if aspirated so use with caution with a poorly mentating patient
When would you give N-acetylcysteine (NAC)?
- The peak absorption of acetaminophen occurs at about 4 hours with acute ingestions
- Use the Rumack–Matthew nomogram to plot the serum level of acetaminophen versus the time since ingestion to see if you are above the treatment line.
- If the ingestion time is unknown then just give it.
How do you dose NAC?
- 3 bag system: First, a 150 mg/kg bolus is administered IV over 15-60 minutes (Bag 1), then a 50 mg/kg drip is administered over 4 hours (Bag 2), then a 100 mg/kg drip is administered over the following 16 hours (Bag 3).
  - This is the Prescott Protocol that requires three bag of IV fluids
- 2 bag system: There is a simplified protocol that only requires 2 bags, 200mg/kg IV over 4 hours (Bag 1) followed by 100mg/kg over 16 hours (Bag 2)
  - Less risk of anaphylactoid reactions with a 2-bag system due to the high rate of IV NAC given in the 3 bag system.
What are the endpoints for stopping NAC?
- If the INR is
- If the acetaminophen level is

References

Hodgman MJ, Garrard AR. A review of acetaminophen poisoning. Crit Care Clin. 2012 Oct;28(4):499-516. doi: 10.1016/j.ccc.2012.07.006. PMID: 22998987.
Rumack BH, Matthew H. Acetaminophen poisoning and toxicity. Pediatrics. 1975 Jun;55(6):871-6. PMID: 1134886.
Sudanagunta S, Camarena-Michel A, Pennington S, Leonard J, Hoyte C, Wang GS. Comparison of Two-Bag Versus Three-Bag N-Acetylcysteine Regimens for Pediatric Acetaminophen Toxicity. Ann Pharmacother. 2023 Jan;57(1):36-43. doi: 10.1177/10600280221097700. Epub 2022 May 19. PMID: 35587124.

Summarized by Jeffrey Olson, MS4 | Edited by Jeffrey Olson and Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Episode 965: Oxygen Administration in Trauma Patients Jul 14, 2025

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Many trauma patients are placed on oxygen via non-rebreather
A large, multicenter, controlled trial evaluated the outcomes of oxygen administration in trauma patients
Patients were randomized to two groups
- 1. 8-hour restrictive oxygen strategy: only receiving oxygen when the patient's saturation dropped below 94% 2. 8-hour liberal oxygen strategy: 12-15 liters of oxygen per minute or fraction of inspired oxygen of 0.6-1.0
The study evaluated rates of death or major respiratory complications at 30 days
There was no statistical difference between the two groups
- Therefore, there is no clear benefit to administering liberal amounts of oxygen to trauma patients, but there is also no clear harm
Ultimately, trauma patients do not need to be on oxygen via non-rebreather unless they are hypoxic or short of breath

References

Arleth T, Baekgaard J, Siersma V, et al. Early Restrictive vs Liberal Oxygen for Trauma Patients: The TRAUMOX2 Randomized Clinical Trial. JAMA. 2025;333(6):479-489. doi:10.1001/jama.2024.25786

Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Episode 964: Ketamine & Midazolam for Prehospital Seizure Management Jul 07, 2025

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Prehospital seizures are typically managed with intramuscular midazolam (Versed)
Seizures theoretically involve the NMDA pathway, and ketamine is a potent NMDA antagonist
A recent retrospective cohort study analyzed a Florida EMS protocol that uses ketamine in seizures refractory to midazolam
- One group received two doses of midazolam for seizure control
- The other group received a dose of midazolam followed by a dose of ketamine
After matching, 82% of the midazolam-only group patients had resolution of convulsions prior to ED arrival
- 94.4% of patients in the midazolam + ketamine group experienced resolution
- Absolute difference between groups was 12.4% (95% CI 3.1% to 21.7%)
Limitations to the study include its prehospital setting and limited long-term follow-up

References

Zitek T, Scheppke KA, Antevy P, et al. Midazolam and Ketamine for Convulsive Status Epilepticus in the Out-of-Hospital Setting. Ann Emerg Med. 2025;85(4):305-312. doi:10.1016/j.annemergmed.2024.11.002

Summarized & Edited by Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Episode 963: Antihypertensives and Emergency Room Considerations Jun 30, 2025

Show notes

Contributor: Alec Coston, MD

Educational Pearls:

For patients presenting to the emergency room with hypertension, clinicians should determine if it is isolated and uncomplicated, or involves comorbidities with more complex underlying pathophysiology.

For uncomplicated and isolated hypertension, first-line treatment is thiazide diuretics.

How do thiazide diuretics work to treat hypertension?

Thiazide diuretics work by blocking sodium and chloride resorption in the kidneys. "Where sodium goes, water follows," thus promoting diuresis and lowering blood pressure.

Examples of thiazide diuretics and their benefits?

Hydrochlorothiazide (HCTZ): First-line medication in uncomplicated and chronic hypertensive states. Cheaper and fewer significant adverse effects compared to chlorthalidone.
HCTZ can be associated with decreased risk of stroke and myocardial infarction.
However, for more complicated hypertension, especially in the setting of heart failure, Angiotensin Converting Enzyme (ACE) Inhibitors should be considered.

How do ACE Inhibitors manage blood pressure?

The body's kidneys drive the Renin-Angiotensin-Aldosterone-System (RAAS) to regulate blood pressure.
It is easiest to understand RAAS as being pro-hypertensive as a response to decreased renal perfusion. As renal perfusion decreases, renin is released and activates angiotensin I, which is converted by ACE to Angiotensin II, which causes release of aldosterone.
ACE Inhibitors prevent the conversion of Angiotensin I to Angiotensin II, thus decreasing the kidneys' production of Angiotensin II and Aldosterone levels.

Why, in the context of heart failure, are ACE Inhibitors preferred?

In heart failure, especially left-sided or left-ventricular heart failure, a vicious cycle can develop wherein the left ventricle fails to perfuse the kidneys due to over-dilation.
The kidneys are hypoperfused and activate RAAS to try to retain volume and increase peripheral vasoconstriction, promoting renal perfusion.
The increase in blood pressure puts further strain on the heart, thereby further decreasing cardiac output. The cycle develops, and extremely elevated blood pressures can develop.
ACE Inhibitors can directly block this cycle, hence their preference in heart failure.

Big takeaway?

In uncomplicated hypertensive patients, consider thiazide diuretics. When comorbidities, especially heart failure, are introduced, then consider ACE Inhibitors.

References

Carey RM, Moran AE, Whelton PK. Treatment of Hypertension: A Review. JAMA. 2022;328(18):1849-1861. doi:10.1001/jama.2022.19590
Fan M, Zhang J, Lee CL, Zhang J, Feng L. Structure and thiazide inhibition mechanism of the human Na-Cl cotransporter. Nature. 2023;614(7949):788-793. doi:10.1038/s41586-023-05718-0
Hripcsak G, Suchard MA, Shea S, et al. Comparison of Cardiovascular and Safety Outcomes of Chlorthalidone vs Hydrochlorothiazide to Treat Hypertension. JAMA Internal Medicine. 2020;180(4):542-551. doi:10.1001/jamainternmed.2019.7454
Yu D, Li JX, Cheng Y, et al. Comparative efficacy of different antihypertensive drug classes for stroke prevention: A network meta-analysis of randomized controlled trials. PLoS One. 2025;20(2):e0313309. doi:10.1371/journal.pone.0313309

Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Our TOPPODCAST Picks

Follow Us

Stay Connected

Related Podcasts

Links

Stay Connected