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 # 433: Geriatric Ketamine Feb 09, 2019

Show notes

Author: Michael Hunt, MD

Educational Pearls:

Recent study compared ketamine to morphine in elderly patient
Ketamine (IV dose 0.3 mg /kg) provided equivalent pain control to morphine (IV dose 0.1 mg / kg)
However, etamine group had much higher rate of side effects, including psychoperceptual
A lower does of 0.1 mg / kg given intravenously over 15 minutes might be a better option to start in the elderly population - you can always add more!

References

Motov S, Mann S, Drapkin J, Butt M, Likourezos A, Yetter E, Brady J, Rothberger N, Gohel A, Flom P, Mai M, Fromm C, Marshall J. Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. Am J Emerg Med. 2019 Feb;37(2):220-227. doi: 10.1016/j.ajem.2018.05.030. Epub 2018 May 16. PubMed PMID: 29807629.

Summarized and edited by Erik Verzemnieks, MD

Podcast # 432: Hunting for UTIs Feb 07, 2019

Show notes

Author: Michael Hunt, MD

Educational Pearls:

As many as 20% of women in assisted living have asymptomatic bacteriuria
This can present a diagnostic conundrum when seeing these patients in the emergency department, particularly for altered mental status and deciding whether to treat
True diagnosis of UTI in the emergency department is difficult as true diagnoses required culture results and repeated positive samples
Procalcitonin is an emerging biomarker that may be helpful in determining the presence of infection

References:

Cortes-Penfield NW, Trautner BW, Jump RLP. Urinary Tract Infection and Asymptomatic Bacteriuria in Older Adults. Infect Dis Clin North Am. 2017 Dec;31(4):673-688. doi: 10.1016/j.idc.2017.07.002. Review. PubMed PMID: 29079155; PubMed Central PMCID: PMC5802407.

Huang DT, Angus DC, Chang CH, Doi Y, Fine MJ, Kellum JA, Peck-Palmer OM, Pike F, Weissfeld LA, Yabes J, Yealy DM; ProACT Investigators.. Design and rationale of the Procalcitonin Antibiotic Consensus Trial (ProACT), a multicenter randomized trial of procalcitonin antibiotic guidance in lower respiratory tract infection. BMC Emerg Med. 2017 Aug 29;17(1):25. doi: 10.1186/s12873-017-0138-1. PubMed PMID: 28851296; PubMed Central PMCID: PMC5576372.

Summarized by Erik Verzemnieks, MD

Podcast # 431: Medication Errors Feb 04, 2019

Show notes

Author: Rachel Brady, MD

Educational Pearls:

Medication errors are estimated to be the 3rd leading cause of death
A 2016 study estimated 250,000 errors occur per year, with 7000-9000 leading to death
About 50% are in the ordering/prescribing phase; 25-30% during administration phase.
Overworked and distracted providers are the most common underlying reasons for medication error
A 2017 study found 40% of ED nurses witnessed a medication error in the last year

Editor's Note: This is a reasonable counterpoint

References

Farag A, Blegen M, Gedney-Lose A, Lose D, Perkhounkova Y. Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. J Emerg Nurs. 2017 May;43(3):246-254. doi: 10.1016/j.jen.2016.10.015. Epub 2017 Mar 28. PubMed PMID: 28359712.

Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139. PubMed PMID: 27143499.

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

Podcast # 430: Humeral IO Jan 30, 2019

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

Choose the longest needle for the humeral IO
Internally rotate and adduct the patients hand (resting on umbilicus) for best access to the site
Aim 1 cm superior to the greater tuberosity of the humerus with the needle angled 45 degrees inferiorly
Maintaining the line is critical - keep arm internally rotated with sling, tape or whatever works

References

Kovar J, Gillum L. Alternate route: the humerus bone - a viable option for IO access. JEMS. 2010 Aug;35(8):52-9. doi: 10.1016/S0197-2510(10)70207-2. PubMed PMID: 20708143.

http://epmonthly.com/article/get-humeral-io-access/

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

Podcast # 429: Oldschool Syphilis Treatment Jan 28, 2019

Show notes

Author: Chris Holmes, MD

Educational Pearls:

In WWI, the 2nd leading cause of soldier disability were STDs.
An early treatment of syphilis included topical and inhaled mercury
Bloodletting, vitriol, arsenic, and bismuth were other treatments for syphilis.
Infecting patients with Malaria and treating the Malaria was also tried
Thankfully penicillin was discovered for our syphilis woes

References

Frith J. . Syphilis – Its early history and Treatment until Penicillin and the Debate on its Origins. Journal of Military and Veterans Health. 2012. 20(4): 49-58 https://jmvh.org/article/syphilis-its-early-history-and-treatment-until-penicillin-and-the-debate-on-its-origins/

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

Podcast # 428: Severe Hypothyroidism Jan 27, 2019

Show notes

Author: Gretchen Hinson, MD

Educational Pearls:

Clinical manifestations of severe hypothyroidism may include:
- Pale, cool, diaphoretic skin
- Myxedema is the non-pitting edema seen in hypothyroidism
- Hypothermia, heart failure, hypotension and shock
- Shortness of breath
- Cholestasis, constipation
- Encephalopathy and coma

Mortality is 30-50%

Specific treatment includes thyroid hormone (T3, T4, or both) and glucocorticoids (for potential adrenal insufficiency)

References:

Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. 2007 Jul-Aug;22(4):224-31. Review. PubMed PMID: 17712058.

Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan. J Epidemiol. 2017 Mar;27(3):117-122. doi: 10.1016/j.je.2016.04.002. Epub 2017 Jan 5. PubMed PMID: 28142035; PubMed Central PMCID: PMC5350620.

Lee CH, Wira CR. Severe angioedema in myxedema coma: a difficult airway in a rare endocrine emergency. Am J Emerg Med. 2009 Oct;27(8):1021.e1-2. doi: 10.1016/j.ajem.2008.12.027. PubMed PMID: 19857436.

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

Podcast # 427: Cookie Dough is Delicious Jan 24, 2019

Show notes

Author: Eric Miller, MD

Educational Pearls:

Recent CDC statement warms against consumption of cookie dough
Two common ingredients can pose risk: eggs and flour
Flour in dough is a raw agricultural product not treated to kill E. coli
A 2016 E. coli outbreak was linked to flour

References:

https://www.cdc.gov/features/no-raw-dough/index.html

https://www.cdc.gov/ecoli/2016/o121-06-16/index.html

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

Podcast # 426: Ho Ho - Oh No! Jan 22, 2019

Show notes

Author: Katrina Iverson, MD

Educational Pearls:

The winter holiday months present a unique picture of patient presentations to the emergency department
- Some of the unique presentations include:
- Children falling off Santa's lap
- Sledding injuries
- Falling off ladders
- Lacerations, ingestion, and insertion of broken ornaments (pediatrics)
Parents tend to hurt themselves on their children's toys

References:

Lauche R, et al. (2018). 'Santa baby, hurry [extra carefully] down the chimney tonight' – Prevalence of Christmas related injuries 2007–2016 in the United States: Observational study. Advances in Integrative Medicine. https://doi.org/10.1016/j.aimed.2018.11.004

https://areyouawellbeing.texashealth.org/common-winter-injuries/

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

Podcast # 425: Oseltamivir Efficacy in Children Jan 18, 2019

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

Recent meta-analysis reviewed efficacy oseltamivir (Tamiflu) in pediatric populations treated for influenza, showing an 18 hour reduction in duration of illness for those with laboratory confirmed influenza
Those with suspected influenza unsurprisingly had less effect
Subgroup analysis showed most benefit in those treated within the first 24 hours of symptom onset
Patients with confirmed influenza treated with oseltamivir had a 34% reduction in risk of otitis media

Editor's note: Vomiting was higher in the treatment groups; There were no significantly different outcomes in regards to other endpoints, such as lower respiratory tract infections and hospitalizations

References:

Malosh RE, Martin ET, Heikkinen T, Brooks WA, Whitley RJ, Monto AS. Efficacy and Safety of Oseltamivir in Children: Systematic Review and Individual Patient Data Meta-analysis of Randomized Controlled Trials. Clin Infect Dis. 2018 May 2;66(10):1492-1500. doi: 10.1093/cid/cix1040. PubMed PMID: 29186364.

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

Podcast # 424: Hunting for Measles Jan 16, 2019

Show notes

Author: Mike Hunt, MD

Educational Pearls:

Measles is highly contagious and successfully infects 90% of those at risk exposed to the virus.
10 day prodrome where patients are asymptomatic.
3 day period of characteristic cough, coryza, conjunctivitis, fever and Koplick spots with a maculopapular rash that moves from head through trunk
Infection risk extends three to four days after the onset of rash but also three to four days prior to onset. Have fun with that.
A potential exposure, say in an emergency department waiting room, needs review of any exposed patient's immunization history to contain spread

References:

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

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