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 # 423: Blunt Cardiac Injuries Jan 14, 2019

Show notes

Author: Mike Hunt, MD

Educational Pearls:

Blunt cardiac injuries most commonly occur in motor vehicle collisions, auto-pedestrian collisions, and from sports injuries
The more anterior right ventricle is the most commonly injured structure
Look for new EKG changes such as bundle branch blocks, ST changes, or other arrhythmias
New EKG abnormalities should prompt consideration of further workup and admission for telemetry
Patients may have an elevated troponin - but it is unclear when exactly this should be drawn after the injury

References:

Bellister SA, Dennis BM, Guillamondegui OD. Blunt and Penetrating Cardiac Trauma. Surg Clin North Am. 2017 Oct;97(5):1065-1076. doi: 10.1016/j.suc.2017.06.012. Review. PubMed PMID: 28958358.

Marcolini EG, Keegan J. Blunt Cardiac Injury. Emerg Med Clin North Am. 2015 Aug;33(3):519-27. doi: 10.1016/j.emc.2015.04.003. Epub 2015 Jun 10. Review. PubMed PMID: 26226863.

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

Podcast # 422: ED Opioid Prescription Trends Jan 11, 2019

Show notes

Author: Jared Scott, MD

Educational Pearls:

From 1996 to 2012, the total quantity of opioids prescribed increased 647% for non-cancer pain
Office based prescriptions accounted for 84% of the total opioid prescriptions, up from 64%
The total share of opioids prescribed from the emergency department declined from 10% to 3.9% but
Total opioids prescribed from the ED still increased 219% over this same time frame

References:

Axeen S, Seabury SA, Menchine M. Emergency Department Contribution to the Prescription Opioid Epidemic. Ann Emerg Med. 2018 Jun;71(6):659-667.e3. doi: 10.1016/j.annemergmed.2017.12.007. Epub 2018 Jan 16. PubMed PMID: 29373155

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

Podcast # 421: Sweet DKA Pearls Jan 09, 2019

Show notes

Author: Gretchen Hinson, MD

Educational Pearls:

Diabetic ketoacidosis patients are subject to electrolyte derangements
Potassium should be monitored closely:
- K
- 3.3
- K > 5.3 = delay potassium replacement
Adult patients are typically severely volume depleted and can require 50 cc/kg bolus or more
Insulin typically given in bolus of 0.1 units/kg followed by drip at 0.1 units/kg/hr

References:

Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606. doi: 10.1016/j.mcna.2016.12.011. Review. PubMed PMID: 28372715.

Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management.Metabolism. 2016 Apr;65(4):507-21. doi: 10.1016/j.metabol.2015.12.007. Epub 2015 Dec 19. Review. PubMed PMID: 26975543.

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

Podcast # 420: CT Contrast and the Kidneys Jan 07, 2019

Show notes

Author: Don Stader, MD

Educational Pearls:

Recent meta-analysis has demonstrated that there is no significant risk for kidney injury from CT contrast
Most kidney injury seen after contrast CTs were due to other underlying illnesses (sepsis, hypovolemia, etc.)
Older contrast agents likely did have nephrotoxic effects but this appears to be a thing of the past

References:

Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR. Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med. 2018 Jan;71(1):44-53.e4. doi: 10.1016/j.annemergmed.2017.06.041. Epub 2017 Aug 12. Review. PubMed PMID: 28811122.

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

Podcast # 419: Etripamil Dec 20, 2018

Show notes

Author: Don Stader, MD

Educational Pearls:

Etripamil is an intranasal calcium channel blocker in development for use in SVT

A recent study showed that etripamil has an SVT conversion rate of around 80%

Etripamil does not have the same feeling of "impending doom" that can occur with adenosine

Editor's note: Etripamil is still in development and these results are from a phase II clinical trial.

References:

Stambler BS, Dorian P, Sager PT, Wight D, Douville P, Potvin D, Shamszad P, Haberman RJ, Kuk RS, Lakkireddy DR, Teixeira JM, Bilchick KC, Damle RS, Bernstein RC, Lam WW, O'Neill G, Noseworthy PA, Venkatachalam KL, Coutu B, Mondésert B, Plat F. Etripamil Nasal Spray for Rapid Conversion of Supraventricular Tachycardia to Sinus Rhythm. J Am Coll Cardiol. 2018 Jul 31;72(5):489-497. doi: 10.1016/j.jacc.2018.04.082. PubMed PMID: 30049309.

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

Podcast # 418: Vertebral Artery Dissection Dec 17, 2018

Show notes

Author: Don Stader, MD

Educational Pearls:

Vertebral artery dissection (VAD) contributes to just 2% of strokes overall but ~25% of strokes for patients
VAD is associated with minor trauma (chiropractic manipulation, yoga), typically with neck extension and rotation.
VAD can cause posterior stroke symptoms (vertigo, diplopia, Horner's Syndrome, Wallenberg Syndrome)
Overall a good prognosis with around 50% of patients recovering without lasting neurologic deficits.

References:

Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009 Jul;8(7):668-78. doi: 10.1016/S1474-4422(09)70084-5. Review. PubMed PMID: 19539238.

Gottesman RF, Sharma P, Robinson KA, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012;18(5):245-54.

Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. Review. PubMed PMID: 11259724.

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

Podcast # 417: Water Balance Dec 15, 2018

Show notes

Author: Katie Sprinkle, MD

Educational Pearls:

Hyponatremia results when patients over hydrate and dilute their sodium with too much free water
Symptoms of hyponatremia can mimic symptoms of dehydration (dizziness, lightheadedness, general malaise)
With severe hyponatremia patients can progress to seizure, coma, and death
Hypernatremia results from dehydration and is more common

References:

Bennett BL, Hew-Butler T, Hoffman MD, Rogers IR, Rosner MH; Wilderness Medical Society.. Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S30-42. doi: 10.1016/j.wem.2014.08.009. PubMed PMID: 25498260.

Braun MM, Barstow CH, Pyzocha NJ. Diagnosis and management of sodium disorders: hyponatremia and hypernatremia. Am Fam Physician. 2015 Mar 1;91(5):299-307. PubMed PMID: 25822386.

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

Podcast # 416: Wide Complex Tachycardia Dec 12, 2018

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

Defined as QRS over 120 ms and rate over 120
Two major rhythms = Vetricular tachycardia (VT) or SVT with aberrancy
Safest approach is to assume it is VT
Synchronized Cardioversion is preferred even for stable VT for multiple reasons including safety and efficacy
Procainamide is preferred pharmacologic option
Amiodarone is less preferred third option
Calcium channel blockers (i.e. diltiazem) can worsen certain rhythms and should be avoided

References:

Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med. 2017 Apr;52(4):484-492. doi: 10.1016/j.jemermed.2016.09.010. Epub 2016 Oct 15. Review. PubMed PMID: 27751700.

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

Podcast # 415: Myofascial Pain Syndrome & Fibromyalgia Dec 10, 2018

Show notes

Author: Ryan Circh, MD

Educational Pearls:

Myofascial pain syndrome (MFPS) is typically unilateral with discrete points of palpable pain
Often secondary to repeated use and poor posture.
MFPS typically responds very well to trigger point injections.
Fibromyalgia is bilateral and diffuse and is thought to have a psychological component
Some of the best pharmacological treatments for fibromyalgia are Tramadol and Flexeril

References:

Tofferi JK, Jackson JL, O'Malley PG. Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Arthritis Rheum. 2004 Feb 15;51(1):9-13. PubMed PMID: 14872449.

Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17;292(19):2388-95. Review. PubMed PMID: 15547167.

Giamberardino MA, Affaitati G, Fabrizio A, Costantini R. Myofascial pain syndromes and their evaluation. Best Pract Res Clin Rheumatol. 2011 Apr;25(2):185-98. doi: 10.1016/j.berh.2011.01.002. Review. PubMed PMID: 22094195.

Borg-Stein J, Iaccarino MA. Myofascial pain syndrome treatments. Phys Med Rehabil Clin N Am. 2014 May;25(2):357-74. doi: 10.1016/j.pmr.2014.01.012. Epub 2014 Mar 17. Review. PubMed PMID: 24787338

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

Podcast # 414: Acute Limb Ischemia Dec 08, 2018

Show notes

Author: Dylan Luyten, MD

Educational Pearls:

Symptoms of acute limb ischemia are the 5 P's: Pulselessness, pain, pallor, paresthesias, and poikilothermia
Sudden onset of non-traumatic extremity pain should raise concern for this diagnosis
Obtaining an ankle brachial index (ABI) can help confirm the diagnosis
Consultation with vascular surgery should be immediately after the clinical diagnosis and before any further delays to obtain further imaging

References:

Santistevan JR. Acute Limb Ischemia: An Emergency Medicine Approach. Emerg Med Clin North Am. 2017 Nov;35(4):889-909. doi: 10.1016/j.emc.2017.07.006. Epub 2017 Aug 23. Review. PubMed PMID: 28987435.

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

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