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 # 457: Stroke Scores Apr 15, 2019

Show notes

Author: Jared Scott, MD

Educational Pearls:

Modified Rankin Score: measure of disability often used to qualify outcomes following stroke = no disability, 6=dead, 0-1 indicate good outcome)
- 0-6 Scale
- 0-1 indicative of good outcome

ASPECT score: uses CT to quantify the extent of changes in the brain due to ischemia
- 0-10 Scale
- 10 areas are assessed on non-contrast CT to assess for early stroke changes
- -1 for each area with these findings
- 8-10 is indicative of better outcomes

References

Aviv RI, Mandelcorn J, Chakraborty S, Gladstone D, Malham S, Tomlinson G, Fox AJ, Symons S. Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment. AJNR Am J Neuroradiol. 2007 Nov-Dec;28(10):1975-80. Epub 2007 Oct 5. PubMed PMID: 17921237.

https://manual.jointcommission.org/releases/TJC2018A/DataElem0569.html

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

Podcast # 456 Hypoglycemia: Not feeling so sweet Apr 12, 2019

Show notes

Author: Jared Scott, MD

Educational Pearls:

Beta-blockers can mask the effects of hypoglycemia
Prolonged/refractory hypoglycemia should raise a suspicion for sulfonylurea (or other oral hypoglycemic) overdose
Interventions to reverse hypoglycemia include feeding the patient, IV dextrose, glucagon
Octreotide can be used as an antidote with sulfonylurea ingestion

Editor's note: Here is an interesting case report on using steroids for severe hypogylcemia caused by insulin overdose. Perhaps another treatment modality to keep in your back pocket?

References

Alsahli M, Gerich JE. Hypoglycemia. Endocrinol Metab Clin North Am. 2013 Dec;42(4):657-76. doi: 10.1016/j.ecl.2013.07.002. Review. PubMed PMID: 24286945.

Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.Emerg Med J. 2005 Jul;22(7):512-5. PubMed PMID: 15983093; PubMed Central PMCID: PMC1726850.

Fasano CJ, O'Malley G, Dominici P, Aguilera E, Latta DR. Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2008 Apr;51(4):400-6. Epub 2007 Aug 30. PubMed PMID: 17764782.

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

Podcast # 455: Hunting for PeeCP Apr 11, 2019

Show notes

Author: Michael Hunt, MD

Educational Pearls:

Like all tests, urine toxicology (utox) screens can have false positives
Prescription medications such as demerol, antipsychotics, ketamine, and tramadol can all produce a false positive utox for PCP
Over-the-counter medication such as dextromethorphan also mimic PCP on utox

References

Doyon S. (January 2014). False Positive Urine Screens for Phencyclidine. ToxTidbits. Retrieved from https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2014/January%202014%20ToxTidbits.pdf

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

Podcast # 454: Tylenol Overdose Apr 09, 2019

Show notes

Educational Pearls:

Acetaminophen overdose can also present in patients taking too much over the course of days to weeks - not just intentional ingestions
If acute overdose is suspected, refer to the Rumak-Matthew nomogram to guide treatment based on time of ingestion and the time of level
In chronic overdose, Tylenol levels will not guide treatment
NAPQI is the toxic metabolite of acetaminophen
N-acetylcysteine (NAC) can be effective treatment in both acute and chronic overdoses
7.5 g is the daily toxic dose of Tylenol in adults, 150mg/kg in children

References:

Smilkstein MJ. Acetaminophen. In: Goldfrank's Toxicologic Emergencies, Goldfrank LR, Flomenbaum NE, Lewin NA, et al (Eds), Appleton & Lange, Stamford 1998. P.541.

Chiew AL, Gluud C, Brok J, Buckley NA. Interventions for paracetamol (acetaminophen) overdose. Cochrane Database Syst Rev. 2018 Feb 23;2:CD003328. doi: 10.1002/14651858.CD003328.pub3. Review. PubMed PMID: 29473717.

Lancaster EM, Hiatt JR, Zarrinpar A. Acetaminophen hepatotoxicity: an updated review. Arch Toxicol. 2015 Feb;89(2):193-9. doi: 10.1007/s00204-014-1432-2. Epub 2014 Dec 24. Review. PubMed PMID: 25537186.

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

Podcast # 453: Headache Triggers Apr 04, 2019

Show notes

Author: Sam Killian, MD

Educational Pearls:

Headache is a common complaint in the ED. It's plausible that headaches could be correlated with environmental factors
A 2015 study ED visits for headache found that temperature was associated with an increase visits, while higher humidity led to fewer
A retrospective study looking over a 10-year period for headache found that there was an increase headache presentations during days with high air pollution

References:

Yilmaz M, Gurger M, Atescelik M, Yildiz M, Gurbuz S. Meteorologic parameters and migraine headache: ED study. Am J Emerg Med. 2015 Mar;33(3):409-13. doi: 10.1016/j.ajem.2014.12.056. Epub 2014 Dec 31. PubMed PMID: 25601162.

Szyszkowicz M, Stieb DM, Rowe BH. Air pollution and daily ED visits for migraine and headache in Edmonton, Canada. Am J Emerg Med. 2009 May;27(4):391-6. doi: 10.1016/j.ajem.2008.03.013. PubMed PMID: 19555607.

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

Podcast # 452: CADASIL Apr 01, 2019

Show notes

Author: Sam Killian, MD

Educational Pearls:

Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) occurs in 1:100000 individuals
The disease is caused by a defect in the NOTCH3 gene on chromosome 19
It is an important cause of stroke in young patients
Features include ischemia, cognitive deficits, migraines, psychiatric disease, coma, and seizure, all of which is worse with pregnancy
Migraine with aura is often the first presenting symptom with onset by age 30
Strokes typically can occur by age 50
Diagnosis is with MRI for characteristic lesions
Unfortunately there is no cure, and treatment is focused on stroke prevention with aspirin and statins

References:

Chabriat H, Joutel A, Dichgans M, Tournier-Lasserve E, Bousser MG. Cadasil. Lancet Neurol. 2009 Jul;8(7):643-53. doi: 10.1016/S1474-4422(09)70127-9. Review. PubMed PMID: 19539236.

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

Podcast # 451: NSAIDs Mar 29, 2019

Show notes

Author: Don Stader, MD

Educational Pearls:

Non-steroidal anti-inflammatory drugs (NSAIDs) are effective pain relievers but come with important side effects
NSAIDs inhibit COX-1 and/or COX-2, which decreases the production of prostaglandins, which reduce pain and inflammation
Side effects of NSAIDS include increased rates myocardial infarction, stroke, and gastrointestinal bleeding, CVA
Effective pain reliever doses of many NSAIDs are lower than typically prescribed (i.e. ibuprofen 400 mg is as effective as 800 mg but with less risk of side effects)
Topical NSAIDs can be an alternative to reduce systemic effects
Selective Cox-2 inhibitors have less GI side effects

Editor note: What is ALTO? It's alternative to opioids and consists of multi-modal pain control to reduce exposure to opioids. Check out more here and here.

References:

Derry S, Wiffen PJ, Kalso EA, Bell RF, Aldington D, Phillips T, Gaskell H, Moore RA. Topical analgesics for acute and chronic pain in adults - an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017 May 12;5:CD008609. doi: 10.1002/14651858.CD008609.pub2. Review. PubMed PMID: 28497473.

Coxib and traditional NSAID Trialists' (CNT) Collaboration., Bhala N, Emberson J, Merhi A, Abramson S, Arber N, Baron JA, Bombardier C, Cannon C, Farkouh ME, FitzGerald GA, Goss P, Halls H, Hawk E, Hawkey C, Hennekens C, Hochberg M, Holland LE, Kearney PM, Laine L, Lanas A, Lance P, Laupacis A, Oates J, Patrono C, Schnitzer TJ, Solomon S, Tugwell P, Wilson K, Wittes J, Baigent C. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013 Aug 31;382(9894):769-79. doi: 10.1016/S0140-6736(13)60900-9. Epub 2013 May 30. PubMed PMID: 23726390; PubMed Central PMCID: PMC3778977.

Kaufman DW, Kelly JP, Battista DR, Malone MK, Weinstein RB, Shiffman S. Exceeding the daily dosing limit of nonsteroidal anti-inflammatory drugs among ibuprofen users. Pharmacoepidemiol Drug Saf. 2018 Mar;27(3):322-331. doi: 10.1002/pds.4391. Epub 2018 Jan 26. PubMed PMID: 29372579.

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

Podcast # 450: Probiotics in Gastroenteritis Mar 27, 2019

Show notes

Author: Sam Killian, MD

Educational Pearls:

Viral gastroenteritis alters the gut microbiome and it is theorized that probiotics may help reduce the duration and severity of the disease.
Double-blind randomized controlled trial involving almost 900 children with viral gastroenteritis compared 5 days of probiotics to a control group.
There was no difference in the rates of severe gastroenteritis between the two groups
Probiotics are likely unhelpful for kid with viral gastroenteritis

References:

Freedman SB, Williamson-Urquhart S, Farion KJ, Gouin S, Willan AR, Poonai N, Hurley K, Sherman PM, Finkelstein Y, Lee BE, Pang XL, Chui L, Schnadower D, Xie J, Gorelick M, Schuh S; PERC PROGUT Trial Group.. Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. N Engl J Med. 2018 Nov 22;379(21):2015-2026. doi: 10.1056/NEJMoa1802597. PubMed PMID: 30462939.

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

Podcast #449: Banana Bags Mar 25, 2019

Show notes

Author: Dylan Luyten, MD

Educational Pearls:

A "banana bag" is a bag of IV fluid that contains various vitamins and minerals including folate and thiamine
IV fluids do not alter intoxicated patients recovery in the emergency department
Folate deficiency is rare in the intoxicated patient
Some intoxicated patients may be thiamine deficient, and those that would benefit the most need significantly more daily thiamine supplementation than provided in a banana bag

References:

Perez SR, Keijzers G, Steele M, Byrnes J, Scuffham PA. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patients in the emergency department: a randomised controlled trial. Emerg Med Australas. 2013 Dec;25(6):527-34. doi: 10.1111/1742-6723.12151. Epub 2013 Nov 8. PubMed PMID: 24308613; PubMed Central PMCID: PMC4253317.

Li SF, Jacob J, Feng J, Kulkarni M. Vitamin deficiencies in acutely intoxicated patients in the ED. Am J Emerg Med. 2008 Sep;26(7):792-5. doi: 10.1016/j.ajem.2007.10.003. PubMed PMID: 18774045.

ay E, Bentham PW, Callaghan R, Kuruvilla T, George S. Thiamine for prevention and treatment of Wernicke-Korsakoff Syndrome in people who abuse alcohol. Cochrane Database Syst Rev. 2013 Jul 1;(7):CD004033. doi: 10.1002/14651858.CD004033.pub3. Review. PubMed PMID: 23818100.

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

Podcast #448: Chronic Salicylate Toxicity Mar 23, 2019

Show notes

Author: Ryan Circh, MD

Educational Pearls:

Chronic salicylate (ASA) toxicity can present in elderly patients as altered mental status
Consider chronic toxicity in patients with an unexplained anion gap acidosis
Treatment for chronic ingestion typically includes IV fluids and urine alkalinization

References:

O'Malley GF. Emergency department management of the salicylate-poisoned patient. Emerg Med Clin North Am. 2007 May;25(2):333-46; abstract viii. Review. PubMed PMID: 17482023.

Durnas C, Cusack BJ. Salicylate intoxication in the elderly. Recognition and recommendations on how to prevent it. Drugs Aging. 1992 Jan-Feb;2(1):20-34. Review. PubMed PMID: 1554971.

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

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