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 # 413: Fascia Iliaca Block Dec 06, 2018

Show notes

Author: Katie Sprinkle, MD

Educational Pearls:

The fascia iliaca block is useful for hip and proximal femur fractures.
Typically involves injecting 40-60 mL of diluted bupivacaine (0.25%) under the fascia iliaca (or other anesthetic)
Anesthesia is achieved of the femoral, obturator, and lateral femoral cutaneous nerves.
Monitor for signs of bupivacaine toxicity (paresthesias, AMS, seizures, arrhythmias)
Intralipid can be an effective treatment for life-threatening toxicity

References:

Hoegberg LC, Bania TC, Lavergne V, Bailey B, Turgeon AF, Thomas SH, Morris M, Miller-Nesbitt A, Mégarbane B, Magder S, Gosselin S; Lipid Emulsion Workgroup.. Systematic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clin Toxicol (Phila). 2016 Mar;54(3):167-93. doi: 10.3109/15563650.2015.1121270. Epub 2016 Feb 6. Review. PubMed PMID: 26853119.

https://www.acepnow.com/article/control-hip-fracture-pain-without-opioids-using-ultrasound-guided-fascia-iliaca-compartment-block/?singlepage=1&theme=print-friendly

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

Podcast #412: tPa Mission Creep Dec 03, 2018

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

Patients with "minor" strokes with NIHSS 0 to 5 can still end up having poor long-term outcomes
Recent study compared use of alteplase vs. aspirin for these patients and saw no difference in regards to favorable neurologic outcome at 90 days
Study was ended early due to patient recruitment difficulties

Editor's note: though ended early, it is debatable whether even if appropriately powered there would have been an identifiable benefit

References:

Khatri P, Kleindorfer DO, Devlin T, Sawyer RN Jr, Starr M, Mejilla J, Broderick J, Chatterjee A, Jauch EC, Levine SR, Romano JG, Saver JL, Vagal A, Purdon B, Devenport J, Pavlov A, Yeatts SD; PRISMS Investigators. Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial. JAMA. 2018 Jul 10;320(2):156-166. doi: 10.1001/jama.2018.8496. PubMed PMID: 29998337.

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

Podcast #411: Mass Casualty Incident Nov 30, 2018

Show notes

Author: Dylan Luyten, MD

Educational Pearls:

Early recognition that the current situation is a mass casualty incident (MCI) is essential with establishing a sole provider/nurse to oversee
Team members labeling themselves by name and role is also helpful
Practice and prepare for these unfortunate events

Editor's note: This podcast comes at the end of a MCI drill over several days

References:

http://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/

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

Podcast #410: FAmbulance Nov 28, 2018

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

Retrospective study looking at type of transportation and mortality outcomes for patients with penetrating trauma
Mortality was 2.2 % for those brought in by private vehicle compared to 11.6% by EMS

Editor's note: the above is raw mortality - even after risk adjustments the odds ratio of death was statistically significant for penetrating injuries, which held true even over multiple trauma systems. Shout out to Dr Haut as well!

References:

Wandling MW, Nathens AB, Shapiro MB, Haut ER. Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System-Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services. JAMA Surg. 2018 Feb 1;153(2):107-113. doi: 10.1001/jamasurg.2017.3601. PubMed PMID: 28975247; PubMed Central PMCID: PMC5838586.

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

Podcast #409: Acute CHF Second Liners Nov 26, 2018

Show notes

Author: Nick Hatch, MD

Educational Pearls:

Quick review on typical treatments for acute CHF:
- Nitrates are a mainstay to reduce preload
- Furosemide has fallen out of favor in regards to urgency but still essential; it can also be utilized in those with poor renal function
Before going into the weeds:
- Phlebotomy can be used to remove volume and may be helpful in certain clinical scenarios
- Trapping venous blood by using blood pressure cuffs on three of four extremities was a very early treatment of CHF

References:

Alzahri MS, Rohra A, Peacock WF. Nitrates as a Treatment of Acute Heart Failure. Card Fail Rev. 2016 May;2(1):51-55. doi: 10.15420/cfr.2016:3:3. PubMed PMID: 28785453; PubMed Central PMCID: PMC5490950.

Paterna S, Di Gaudio F, La Rocca V, Balistreri F, Greco M, Torres D, Lupo U, Rizzo G, di Pasquale P, Indelicato S, Cuttitta F, Butler J, Parrinello G. Hypertonic Saline in Conjunction with High-Dose Furosemide Improves Dose-Response Curves in Worsening Refractory Congestive Heart Failure. Adv Ther. 2015 Oct;32(10):971-82. doi: 10.1007/s12325-015-0254-9. Epub 2015 Oct 31. PubMed PMID: 26521190; PubMed Central PMCID: PMC4635178.

Huijskes RV, Hoogenberg K, Wiesfeld AC, Pijl ME, van Gelder IC. Phlebotomies as a treatment of serious heart failure due to haemochromatosis: a case report. Neth Heart J. 2009;17(11):438-41.

Burch, George E., and Nicholas P. DePasquale. "Congestive Heart Failure—Acute Pulmonary Edema." JAMA 208.10 (1969): 1895-1897.

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

Podcast #408: Go the hell to sleep Nov 23, 2018

Show notes

Author: Don Stader, MD

Educational Pearls:

Recent study showed efficacy 5mg IM midazolam > 10mg IM olanzapine > 10mg IM haloperidol for quickly sedating an agitated patient
If you have access, ketamine intravenous is the fastest
Olanzapine should be used with caution in elderly patients because of its anticholinergic properties
Ketamine can transiently worsen psychosis in some mental illness
Haloperidol is contraindicated in patients with prolonged QT
Olanzapine can be safely given intravenous as another option to your sedating arsenal

References:

Klein LR, Driver BE, Miner JR, Martel ML, Hessel M, Collins JD, Horton GB, Fagerstrom E, Satpathy R, Cole JB. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):374-385. doi: 10.1016/j.annemergmed.2018.04.027. Epub 2018 Jun 7. PubMed PMID: 29885904.

Chew ML, Mulsant BH, Pollock BG, Lehman ME, Greenspan A, Kirshner MA, Bies RR, Kapur S, Gharabawi G. A model of anticholinergic activity of atypical antipsychotic medications. Schizophr Res. 2006 Dec;88(1-3):63-72. Epub 2006 Aug 22. PubMed PMID: 16928430.

Mankowitz SL, Regenberg P, Kaldan J, Cole JB. Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. J Emerg Med. 2018 Nov;55(5):670-681. doi: 10.1016/j.jemermed.2018.07.017. Epub 2018 Sep 7. PubMed PMID: 30197153.

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

Podcast #407: Choose your own blister adventure Nov 21, 2018

Show notes

Author: Don Stader, MD

Educational Pearls:

Three options for a blister in partial thickness burns: do nothing, unroof it, or poke a hole in it
Recent study suggest that aspirating the blister may be more effective in regards to wound healing
The overlying skin acts as a bio-band-aid and patients recover slightly faster

References:

Ro HS, Shin JY, Sabbagh MD, Roh SG, Chang SC, Lee NH. Effectiveness of aspiration or deroofing for blister management in patients with burns: A prospective randomized controlled trial. Medicine (Baltimore). 2018 Apr;97(17):e0563. doi: 10.1097/MD.0000000000010563. PubMed PMID: 29703044; PubMed Central PMCID: PMC5944508.

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

Podcast #406: PO vs. IV Tylenol Nov 19, 2018

Show notes

Author: Don Stader, MD

Educational Pearls:

Intravenous Tylenol currently is many times more expensive than oral
Single ED study comparing the two has methodology flaws and there is a lack of additional evidence to support intravenous over oral formulations solely for pain control
Oral Tylenol appears to be at least equally efficacious, though with a slightly slower onset of action

References:

Furyk J, Levas D, Close B, Laspina K, Fitzpatrick M, Robinson K, Vangaveti VN, Ray R. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial. Emerg Med J. 2018 Mar;35(3):179-184. doi: 10.1136/emermed-2017-206787. Epub 2017 Dec 15. PubMed PMID: 29247042.

Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making. Can J Hosp Pharm. 2015 May-Jun;68(3):238-47. Review. PubMed PMID: 26157186; PubMed Central PMCID: PMC4485512.

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

Podcast #405: Infant Walkers Nov 16, 2018

Show notes

Author: Don Stader, MD

Educational Pearls:

Recent study has revealed that infant walkers are more harmful than helpful
Infant walkers can also delay motor function
The American Academy of Pediatrics calls for a ban on walkers as they are a preventable cause of injury

References:

Siegel AC, Burton RV. (1999).Effects of baby walkers on motor and mental development in human infants. Journal of Developmental and Behavioral Pediatrics. 20:355–361.

Sims A, et al. (2018). Infant Walker-Related Injuries in United States. Pediatrics 142(4).

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

Podcast #404: Electric Scooter Injuries Nov 14, 2018

Show notes

Author: Sam Killian, MD

Educational Pearls:

Recent news articles are showing an increase in injuries related to riding electric scooters
Year-to-year, scooter injuries have increased as high as three to four times
More definitive evidence still to come

Editor's note: don't follow birdgraveyard on instagram

References:

https://www.washingtonpost.com/business/economy/scooter-use-is-rising-in-major-cities-so-are-trips-to-the-emergency-room/2018/09/06/53d6a8d4-abd6-11e8-a8d7-0f63ab8b1370_story.html?noredirect=on&utm_term=.a6e46ff35bdc

https://kutv.com/news/local/er-doctors-report-161-increase-in-scooter-injuries-in-downtown-salt-lake-city

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

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