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 #443: Measles - a timely revisit Mar 04, 2019

Show notes

Author: Sue Chilton, MD

Educational Pearls:

Measles is highly contagious
Typically patients just look sick
Remember 4 & 4, 14, and 4-C's:
- Contagious 4 days before and after onset of rash
- 14 days for rash to appear
- Cough, coryza, conjunctivitis (non-purulent), and Koplik's spots
Under 2 and over 20 are highest risk groups
1 in 1000 will die
Subacute sclerosing panencephalitis is one of the most feared, degenerative, 100% fatal complications that can occur up to two decades after initial infection

Editor's Note: Don't be pro-plague - if you can, vaccinate your children.

References:

https://www.denverpost.com/2019/01/16/denver-measles-exposure/

Moss WJ. Measles. Lancet. 2017 Dec 2;390(10111):2490-2502. doi: 10.1016/S0140-6736(17)31463-0. Epub 2017 Jun 30. Review. PubMed PMID: 28673424.

Bester JC. Measles and Measles Vaccination: A Review. JAMA Pediatr. 2016 Dec 1;170(12):1209-1215. doi: 10.1001/jamapediatrics.2016.1787. Review. PubMed PMID: 27695849.

Summarized and edited by Erik Verzemnieks, MD

Podcast #442: When a severe man cold isn't Mar 02, 2019

Show notes

Author: Jared Scott, MD

Educational Pearls:

CXR is 40-90% sensitive for detecting pneumonia when compared to CT
Patients with a high degree of suspicion for pneumonia may still warrant treatment despite a negative CXR

References:

Self WH, Courtney DM, McNaughton CD, Wunderink RG, Kline JA. High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patients: implications for diagnosing pneumonia. Am J Emerg Med. 2013 Feb;31(2):401-5. doi: 10.1016/j.ajem.2012.08.041. Epub 2012 Oct 18. PubMed PMID: 23083885; PubMed Central PMCID: PMC3556231.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast #441: Is Heparin Worthless for ACS? Feb 27, 2019

Show notes

Author: Don Stader, MD

Educational Pearls:

Recent study demonstrated patients with non-STEMI treated with heparin had no difference in survival, but had an increased risk of major bleeding
Heparin may be an outdated medication in the era of dual anti-platelet therapy and PCI
Heparin may fall to the wayside like other former treatments for ACS such as morphine, oxygen and nitroglycerin as far as mortality benefit

References:

Chen JY, He PC, Liu YH, Wei XB, Jiang L, Guo W, Duan CY, Guo YS, Yu XP, Li J, Li WS, Zhou YL, Lin CY, Luo JF, Yu DQ, Chen ZJ, Chen W, Chen YY, Guo ZQ, Geng QS, Tan N. Association of Parenteral Anticoagulation Therapy With Outcomes in Chinese Patients Undergoing Percutaneous Coronary Intervention for Non-ST-Segment Elevation Acute Coronary Syndrome. JAMA Intern Med. 2019 Feb 1;179(2):186-194. doi: 10.1001/jamainternmed.2018.5953. PubMed PMID: 30592483

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 440 : Carbon Monoxide Poisoning Feb 25, 2019

Show notes

Author: Katie Sprinkle, MD

Educational Pearl:

Carbon monoxide (CO) is the leading cause of death from poison world-wide
CO forms from the combustion of any carbon based product
Patients often present with non specific symptom like headache, vomiting, and malaise
Consider this diagnosis with multiple people presenting with similar symptoms from a single location
Treatment is with high flow oxygen (i.e. non-rebreather)
Hyperbaric therapy is controversial and up for debate - discussion with local consultants may help guide this management/transfer
Tobacco smokers typically have elevated levels of carbon monoxide at baseline

Editor's Note: smoking hookah for one hour may be the equivalent of smoking nearly 100 cigarettes

References:

Jacob P, Abu Raddaha AH, Dempsey D, et al. Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe. Cancer Epidemiol Biomarkers Prev. 2011;20(11):2345-53.

Ng PC, Long B, Koyfman A. Clinical chameleons: an emergency medicine focused review of carbon monoxide poisoning. Intern Emerg Med. 2018 Mar;13(2):223-229. doi: 10.1007/s11739-018-1798-x. Epub 2018 Feb 12. Review. Erratum in: Intern Emerg Med. 2018 Mar 22;:. PubMed PMID: 29435715.

American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Carbon Monoxide Poisoning:., Wolf SJ, Maloney GE, Shih RD, Shy BD, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning. Ann Emerg Med. 2017 Jan;69(1):98-107.e6. doi: 10.1016/j.annemergmed.2016.11.003. PubMed PMID: 27993310.

Guzman JA. Carbon monoxide poisoning. Crit Care Clin. 2012 Oct;28(4):537-48. doi: 10.1016/j.ccc.2012.07.007. Review. PubMed PMID: 22998990.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 438 : tPA for Frostbite Feb 22, 2019

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

Several studies have shown administration of tPA can improve outcomes and reduce need for amputation
tPA is considered in grade III and IV frostbite
tPA cannot be given until after the warming process
Administration is systemically, not catheter directed or intra-arterial

References:

Jones LM, Coffey RA, Natwa MP, Bailey JK. The use of intravenous tPA for the treatment of severe frostbite. Burns. 2017 Aug;43(5):1088-1096. doi: 10.1016/j.burns.2017.01.013. Epub 2017 Jan 31. PubMed PMID: 28159151.

Wexler A, Zavala S. The Use of Thrombolytic Therapy in the Treatment of Frostbite Injury. J Burn Care Res. 2017 Sep/Oct;38(5):e877-e881. doi: 10.1097/BCR.0000000000000512. PubMed PMID: 28296671.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 439 : Oops I did it again Feb 22, 2019

Show notes

Author: Aaron Lessen, MD

Educational Pearl:

A double ingestion of a single pill is typically a benign event but several drug classes may cause problems
A published review of 10 years of single medication double dose ingestion found 12 out of 876 cases had adverse events. The drugs and events were:
- Propafenone ingestion leading to ventricular tachycardia
- Beta blocker ingestion leading to bradycardia and hypotension
- Calcium channel blocker leading to bradycardia and hypotension
- Bupropion ingestion leading to seizures
- Tramadol ingestion leading to ventricular tachycardia

Editor's Note:

References:

Correia MS, Whitehead E, Cantrell FL, Lasoff DR, Minns AB. A 10-year review of single medication double-dose ingestions in the nation's largest poison control system. Clin Toxicol (Phila). 2019 Jan;57(1):31-35. doi: 10.1080/15563650.2018.1493205. Epub 2018 Nov 28. PubMed PMID: 30484705.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 437 : Myasthenia Gravis Feb 20, 2019

Show notes

Podcast # 437 : Myasthenia Gravis

Author: Gretchen Hinson, MD

Educational Pearls:

Myasthenia gravis (MG) is an antibody mediated autoimmune disorder against the acetylcholine receptors at the neuromuscular junctions.
Bimodal age distribution (20's-30's: women; 60's-70's: men)
Presents with fluctuating muscle weakness typically worse at the end of the day with upper extremities affected more than lower and typically involving facial muscles.
Myasthenia crisis occurs when muscle fatigue begins to cause respiratory depression
MG was historically diagnosed with the Tensilon test but now often by EMG
Treatment of MG crisis involves plasma exchange and IVIG. Those in crisis often require intubation and ICU admission

References:

Gilhus NE. Myasthenia Gravis. N Engl J Med. 2016 Dec 29;375(26):2570-2581. doi: 10.1056/NEJMra1602678. Review. PubMed PMID: 28029925.

Roper J, Fleming ME, Long B, Koyfman A. Myasthenia Gravis and Crisis: Evaluation and Management in the Emergency Department. J Emerg Med. 2017 Dec;53(6):843-853. doi: 10.1016/j.jemermed.2017.06.009. Epub 2017 Sep 12. PubMed PMID: 28916122.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 436 : Epinephrine Autoinjectors Feb 18, 2019

Show notes

Author: Charleen Gnisci, PharmD

Educational Pearls:

Between 2011 to 2016, Mylan increased EpiPen prices by 400% ($700 for 2 packs)
AUVI-Q was recalled in 2012, which left the market share to the EpiPen until recently
Teva announced last year it will be making a generic version of the EpiPen retailing around $300 but expected to decrease

References:

Kaplan, S. F.D.A. Approves Generic EpiPen That May Be Cheaper. The New York Times, The New York Times, 2018. Retrived from www.nytimes.com/2018/08/16/health/epipen-generic-drug-prices.html.

Tirrell, M. FDA approves Teva's generic EpiPen after yearslong delay. 2018. Retrieved from https://www.cnbc.com/2018/08/16/fda-approves-tevas-generic-epipen-after-years-long-delay.html

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 435 : UCL Injury Feb 15, 2019

Show notes

Author: Ryan Circh, MD

Educational Pearls:

Ulnar collateral ligament injury is often called gamekeeper's thumb or skier's thumb
Can results from traumatic deviating the thumb radially (abduction)
Poor rabbits
Have a low threshold for referral to hand surgery for follow up - treatment for minor injuries can be conservative but more severe require surgery to preserve function
This injury should be placed in a thumb spica splint
Radiographs are often negative unless an avulsion fracture is present

Editor's note: to test for UCL injuries, I like this.

References:

Schroeder NS, Goldfarb CA. Thumb ulnar collateral and radial collateral ligament injuries. Clin Sports Med. 2015 Jan;34(1):117-26. doi: 10.1016/j.csm.2014.09.004. Epub 2014 Oct 11. Review. PubMed PMID: 25455399.

Madan SS, Pai DR, Kaur A, Dixit R. Injury to ulnar collateral ligament of thumb. Orthop Surg. 2014 Feb;6(1):1-7. doi: 10.1111/os.12084. Review. PubMed PMID: 24590986.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 434 : TIA Feb 13, 2019

Show notes

Author: Peter Bakes, MD

Educational Pearl:

Transient ischemic attack (TIA) is defined as neurologic symptoms that resolve in 24 hours with no new changes on head imaging
Mimics include complex migraine, carotid dissection, seizure (Todd's paralysis)
Typical presentation is with sudden onset of negative symptoms such as numbness, weakness, etc.
Mimics tend to have positive symptoms such as photophobia, pain, etc.

References:

Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160.

Simmons B, et al. Transient Ischemic Attack: Part I. Diagnosis and Evaluation. American Family Physician 2012; 86(6):521-526.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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