Emergency Medical Minute

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Health & Fitness
**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 #403: Meniscus Lock Nov 12, 2018

Show notes

Author: Mark Hinton, MD

Educational Pearls:

Meniscus lock can occur with a tear leading to inability to extend the knee
Treatment can include an intra-articular joint block followed by straightening
Medial meniscus injuries are more common

References:

Allum RL, Jones JR. The locked knee. Injury. 1986 Jul;17(4):256-8. PubMed PMID: 3770920.

Critchley IJ, Bracey DJ. The acutely locked knee--is a manipulation worth while? Injury. 1985 Jan;16(4):281-3. PubMed PMID: 3967919.

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

Podcast #402: Rapid sequence intubation medications Nov 09, 2018

Show notes

Educational Pearls:

RSI includes induction agent (sedative) and a paralytic
Succinylcholine is a depolarizing paralytic of rapid onset and short duration with contraindications in hyperkalemic states and muscular dystrophy
Rocuronium and vecuronium are longer acting, non-depolarizing paralytic, more commonly
Common induction agents are etomidate and ketamine
Ketamine can be particularly beneficial for bronchodilator effects in those with reactive airway disease

References:

Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother. 2014 Jan;48(1):62-76. doi: 10.1177/1060028013510488. Epub 2013 Nov 4. Review. PubMed PMID: 24259635.

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

Podcast #401: Foreign Body Aspiration Nov 06, 2018

Show notes

Author: Gretchen Hinson, MD

Educational Pearls:

Diagnosis can be difficult and often delayed
Asymmetric breath sounds, choking, stridor may be present, but children also present asymptomatically
Peak incidence around one to two years of age
Hot dogs, nuts, popcorn – round and smooth objects are most commonly aspirated

References:

Green SS. Ingested and Aspirated Foreign Bodies. Pediatr Rev. 2015 Oct;36(10):430-6. doi: 10.1542/pir.36-10-430. Review. PubMed PMID: 26430203.

Sink JR, Kitsko DJ, Georg MW, Winger DG, Simons JP. Predictors of Foreign Body Aspiration in Children. Otolaryngol Head Neck Surg. 2016 Sep;155(3):501-7. doi: 10.1177/0194599816644410. Epub 2016 Apr 12. PubMed PMID: 27071446.

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

Podcast #400: ECMO Nov 02, 2018

Show notes

Author: Dylan Luyten, MD

Educational Pearls:

Extracorporeal membrane oxygenation (ECMO) is similar to bypass
ECMO is being utilized routinely at some centers and even prehospital in cardiac arrest
There are two general types of ECMO:
- Venovenous (VV-ECMO) is useful when the patient cannot oxygenate but has adequate heart function.
- Venoarterial (VA-ECMO) is more like typical bypass and can be used in a pulseless patient

References:

Ouweneel DM, Schotborgh JV, Limpens J, Sjauw KD, Engström AE, Lagrand WK, Cherpanath TGV, Driessen AHG, de Mol BAJM, Henriques JPS. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med. 2016 Dec;42(12):1922-1934. doi: 10.1007/s00134-016-4536-8. Epub 2016 Sep 19. Review. PubMed PMID: 27647331; PubMed Central PMCID: PMC5106498.

Tonna JE, Johnson NJ, Greenwood J, Gaieski DF, Shinar Z, Bellezo JM, Becker L, Shah AP, Youngquist ST, Mallin MP, Fair JF 3rd, Gunnerson KJ, Weng C, McKellar S; Extracorporeal REsuscitation ConsorTium (ERECT) Research Group.. Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO). Resuscitation. 2016 Oct;107:38-46. doi: 10.1016/j.resuscitation.2016.07.237. Epub 2016 Aug 11. PubMed PMID: 27523953; PubMed Central PMCID: PMC5475402.

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

Podcast #399: Hunting for pancreatitis Oct 31, 2018

Show notes

Author: Michael Hunt, MD

Educational Pearls:

Alcohol and gallstones are most common causes of pancreatitis
Diagnosis is not simply based on lipase alone - must have at least two the the three criteria:
- Elevated lipase (greater than 3x upper limit of reference range)
- Typical pain (epigastric pain, radiating to back, etc.)
- Radiographic findings suggestive of pancreatitis (CT, MRI, US)
BISAP criteria can help risk stratify mortality in pancreatitis. You get 1 point for each of the following:
- BNP > 25
- Impaired mental status
- SIRS criteria, more than 2
- AGE > 60
- Pleural effusion
BISAP score of 0 has

Editor's note: The severity of pancreatitis does not correlate with serum lipase levels - notice how it is not used in the BISAP criteria, as an example. Even a mild elevation in serum testing can result in severe pancreatitis.

References:

Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis Classification Working Group.. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25. PubMed PMID: 23100216.

Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A, Whitcomb DC. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol. 2010 Feb;105(2):435-41; quiz 442. doi: 10.1038/ajg.2009.622. Epub 2009 Oct 27. PubMed PMID: 19861954.

Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698-703. doi: 10.1136/gut.2008.152702. Epub 2008 Jun 2. PubMed PMID: 18519429.

Podcast #398: Who is gonna fail your antibiotic plan? Oct 29, 2018

Show notes

Author: Erik Verzemnieks, MD

Educational Pearls:

Recent study provides at least some evidence to help predict antibiotic failure for cellulitis, which is not necessarily straight forward
Intuitive risk factors such as recent cellulitis, chronic ulcers, history of MRSA are associated with antibiotic treatment failure
Oddly, tachypnea at triage was associated with the highest odds ratio for treatment failure

References:

Yadav K, Suh KN, Eagles D, MacIsaac J, Ritchie D, Bernick J, Thiruganasambandamoorthy V, Wells G, Stiell IG. Predictors of Oral Antibiotic Treatment Failure for Nonpurulent Skin and Soft Tissue Infections in the Emergency Department. Acad Emerg Med. 2018 Jun 5. doi: 10.1111/acem.13492.

Summarized and edited by Erik Verzemnieks, MD

Podcast #397: Oh… Pharyngeal Trauma Oct 27, 2018

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

Injuries from penetrating pharyngeal trauma are often subtle on examination in children
Potentially serious complications including carotid artery injury, mediastinitis from spreading infection, or airway compromise from hematoma formation
Imaging choice is typically CTA to assess for vascular injuries
These injuries may require antibiotics

References:

Zonfrillo MR, Roy AD, Walsh SA. Management of pediatric penetrating oropharyngeal trauma. Pediatr Emerg Care. 2008 Mar;24(3):172-5. doi: 10.1097/PEC.0b013e3181669072. PubMed PMID: 18347498.

Sasaki T, Toriumi S, Asakage T, Kaga K, Yamaguchi D, Yahagi N. The toothbrush: a rare but potentially life-threatening cause of penetrating oropharyngeal trauma in children. Pediatrics. 2006 Oct;118(4):e1284-6. PubMed PMID: 17015515.

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

Podcast #396: Oncologic Emergencies Oct 24, 2018

Show notes

Author: Rachel Brady, MD

Educational Pearls:

Hypercalcemia of malignancy:

Hypercalcemia of malignancy can present with lethargy, muscle weakness, hyperreflexia, altered mental status, cardiac dysrhythmias, and even cardiac arrest.
Treatment is based both on calcium level and symptoms
Intravenous rehydration is first line treatment
Other options include steroids, bisphosphonates and calcitonin.

Tumor Lysis Syndrome

Occurs due to the breakdown of tumor cells after chemotherapy/radiation
Presents as hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia
Treatment is very similar to severe hypercalcemia - hydration with crystalloids
Hyperuricemia can be treated using rasburicase or allopurinol

References:

Ñamendys-Silva SA, Arredondo-Armenta JM, Plata-Menchaca EP, Guevara-García H, García-Guillén FJ, Rivero-Sigarroa E, Herrera-Gómez A. Tumor lysis syndrome in the emergency department: challenges and solutions. Open Access Emerg Med. 2015 Aug 20;7:39-44. doi: 10.2147/OAEM.S73684. eCollection 2015. Review. PubMed PMID: 27147889; PubMed Central PMCID: PMC4806807.

Zagzag J, Hu MI, Fisher SB, Perrier ND. Hypercalcemia and cancer: Differential diagnosis and treatment. CA Cancer J Clin. 2018 Sep;68(5):377-386. doi: 10.3322/caac.21489. Epub 2018 Sep 21. Review. PubMed PMID: 30240520.

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

Podcast #395: Aspirin for everyone! Oct 22, 2018

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

In patients without indications for aspirin, three recent studies looked at prevention of several end points in the elderly
These showed no benefit in preventing cardiovascular events (stroke, MI, hear failure), disability, or death in elderly
These studies also demonstrated higher mortality and increased bleeding risk in patients who were taking aspirin without clear indications

Editor's note: the increased all cause mortality is intriguing - but attributed to an increase in cancer mortality. Unclear why but will be important to see if this trend is seen in other studies.

References:

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1499-1508. doi: 10.1056/NEJMoa1800722. Epub 2018 Sep 16. PubMed PMID: 30221596.

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1509-1518. doi: 10.1056/NEJMoa1805819. Epub 2018 Sep 16. PubMed PMID: 30221597.

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1519-1528. doi: 10.1056/NEJMoa1803955. Epub 2018 Sep 16. PubMed PMID: 30221595.

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

Podcast #394: Myths of Medication Assisted Treatment Oct 20, 2018

Show notes

Author: Katie Sprinkle, MD

Educational Pearls:

Medication Assisted Treatment (MAT) is the treatment of addiction with medications, commonly used for opioid use disorders
A long held belief is MAT simply replaces one addiction for another, which is patently false
MAT is one of the most affective methods to treat a patient with opioid addiction
Unfortunately, outdated requirements for prescribers along further prevent its widespread use

References:

Salsitz E, Wiegand T. Pharmacotherapy of Opioid Addiction: "Putting a Real Face on a False Demon." Journal of Medical Toxicology. 2016;12(1):58-63. doi:10.1007/s13181-015-0517-5.

Duber HC, Barata IA, Cioè-Peña E, Liang SY, Ketcham E, Macias-Konstantopoulos W, Ryan SA, Stavros M, Whiteside LK. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):420-431. doi: 10.1016/j.annemergmed.2018.04.007. Epub 2018 Jun 5. Review. PubMed PMID: 29880438.

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

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