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 #393: Neonatal Vomiting Oct 17, 2018

Show notes

Author: Peter Bakes, MD

Educational Pearls:

Important historical information to elicit is the birth history, feeding habits, stooling habits, associated symptoms, presence of bile, and presence of trauma.
Volvulus is a common etiology of intestinal obstruction and is often due to malrotation in utero.

Editor's note: get an upper GI series if there is any bilious vomiting in a neonate. Any time of the night. Wake people up. Transfer if necessary to get the study. This can diagnose volvulus and save bowel.

References:

Ratnayake K, Kim TY. Evidence-based management of neonatal vomiting in the emergency department. Pediatr Emerg Med Pract. 2014 Nov;11(11):1-20; Review. PubMed PMID: 25928976.

Burge DM. The management of bilious vomiting in the neonate. Early Hum Dev. 2016 Nov;102:41-45. doi: 10.1016/j.earlhumdev.2016.09.002. Epub 2016 Sep 12. Review. PubMed PMID: 27634337.

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

Podcast # 392: Maggot Therapy Oct 15, 2018

Show notes

Author: Jared Scott, MD

Educational Pearls:

Interest started as it was noticed soldiers who had wounds infected with maggots had better outcomes than those without maggots
Studies have shown that wound care with maggots is essentially equivalent to traditional therapy with oxygen, antibiotics, and debridement
Maggots debride the wound with proteolytic enzymes, sterilize the wound, and stimulate wound healing

References:

Sherman RA. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009 Mar 1;3(2):336-44. Review. PubMed PMID: 20144365; PubMed Central PMCID: PMC2771513.

Baer WS. The treatment of chronic osteomyelitis with the maggot (larva of the blow fly) J Bone & Joint Surg. 1931;13:438–475. DOI: 10.1007/s11999-010-1416-3

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

Podcast # 391: Necrotizing Fasciitis Oct 12, 2018

Show notes

Author: Peter Bakes, MD

Educational Pearls:

Necrotizing fasciitis is an infection of the deep soft tissues with destruction of the muscle fascia and overlying fat
Think of it if pain is out of proportion to your exam
Polymicrobial and Clostridium species typically cause condition in susceptible individuals (immunocompromised, diabetics, obese, penetrating injury)
Group A strep typically is less specific and can cause necrotizing infections in otherwise healthy individuals
Treatment is typically rapid surgical debridement in addition to broad spectrum antibiotics in addition to clindamycin

References:

Breyre A, Frazee BW. Skin and Soft Tissue Infections in the Emergency Department. Emerg Med Clin North Am. 2018 Nov;36(4):723-750. doi: 10.1016/j.emc.2018.06.005. Review. PubMed PMID: 30297001.

Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7;377(23):2253-2265. doi: 10.1056/NEJMra1600673. Review. PubMed PMID: 29211672.

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

Podcast # 390: Haloperidol for Pain Oct 10, 2018

Show notes

Author: Gretchen Hinson, MD

Educational Pearls:

Reasonable approach of haloperidol 10 mg IM (or 5 mg IV) for pain relief in opioid-dependent patients; can repeat once
Chronic opioid use results in hyperalgesia and a narrow therapeutic window in the long-term so alternatives are essential
Consider the risk of QTc prolongation with haloperidol, particularly if the patient is on other drugs that may do so

Editor's note: Interested in more alternatives to opioids? Check out the Colorado ACEP Opioid Prescribing & Treatment Guidelines and the impact these have had in Colorado

References:

http://ercast.libsyn.com/haloperidol-for-analgesia

Ramirez R, Stalcup P, Croft B, Darracq MA. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med. 2017 Aug;35(8):1118-1120. doi: 10.1016/j.ajem.2017.03.015. Epub 2017 Mar 12. PubMed PMID: 28320545.

Seidel S, Aigner M, Ossege M, Pernicka E, Wildner B, Sycha T. Antipsychotics for acute and chronic pain in adults. Cochrane Database Syst Rev. 2013 Aug 29;(8):CD004844. doi: 10.1002/14651858.CD004844.pub3. Review. PubMed PMID: 23990266.

Podcast #389: BRUE Oct 08, 2018

Show notes

Educational Pearls:

BRUE (Brief Resolved Unexplained Event) replaces what was previously called ALTE

BRUE describes an event in a child less than one year of age with one or more of the following:
- cyanosis or pallor
- absent, decreased, or irregular breathing
- decreased or increased tone
- altered responsiveness

These must be sudden, brief, and now resolved and without an alternative explanation after a history and physical exam

Low risk patients can be safely discharged with reassurance

Low risk criteria must all be present:
- Age over 60 days old
- >32 weeks gestational age at birth and adjusted gestational age > 45 weeks)
- No CPR was performed (by a trained medical professional)
- First event
- Duration less than 1 minute of event

Patients who satisfy above criteria can be considered low risk and may be discharged after minimal/no workup

References:

Tieder JS, Bonkowsky JL, Etzel RA, et al. Clinical Practice Guideline: Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016:137(5):e20160591. Pediatrics. 2016 Aug;138(2). pii: e20161488. doi: 10.1542/peds.2016-1488. PubMed PMID: 27474017.

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

Podcast #388: Antibiotics for Appendicitis Oct 05, 2018

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

5-year follow up study on antibiotic treatment for uncomplicated appendicitis showed 39.1% recurrence rate requiring appendectomy by 5 years

Nearly 60% chance then of preventing an appendectomy by using antibiotics only for uncomplicated appendicitis

Editor's note: not surprisingly, complications were much higher in the group receiving surgery, which reiterates why an antibiotic-only approach is attractive for the right patient population

References:

Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Mecklin JP, Sand J, Virtanen J, Jartti A, Grönroos JM. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018 Sep 25;320(12):1259-1265. doi: 10.1001/jama.2018.13201. PubMed PMID: 30264120.

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

Podcast #387: Fluoroquinolones are Perfectly Safe? Oct 03, 2018

Show notes

Author: Don Stader, MD

Educational Pearls:

Fluoroquinolones can cause connective tissue disruption leading not only to tendon rupture but also aortic dissection

Retrospective study from Taiwan showed over a 2x higher rate of dissection when exposed to fluoroquinolones (1.6% vs 0.6%)

Remember to think about aortic dissection when you have a patient with chest pain that travels and/or involves neurologic symptoms

Try to use fluoroquinolones when no other appropriate antibiotic exists as they have significant other side effects as well

Editor's note: In July 2018, the FDA required strengthening of warning labels on fluoroquinolones about the risks of mental health effects and hypoglycemia

References:

Lee CC, Lee MG, Hsieh R, Porta L, Lee WC, Lee SH, Chang SS. Oral Fluoroquinolone and the Risk of Aortic Dissection. J Am Coll Cardiol. 2018 Sep 18;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067. PubMed PMID: 30213330.

Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin Infect Dis. 2003 Jun 1;36(11):1404-10. Epub 2003 May 20. Review. PubMed PMID: 12766835.

https://www.fda.gov/downloads/Drugs/DrugSafety/UCM612834.pdf

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

Podcast #386: Respecting Transgender Patients Oct 01, 2018

Show notes

Author: Kasey Champion, MD

Educational Pearls:

Transgender populations are frequent victims of discrimination in healthcare

Ask transgender patients what their preferred pronoun is

It is sometimes important to ask about transition status (i.e. on hormones, surgery)

References:

Chisolm-Straker M, Willging C, Daul AD, McNamara S, Sante SC, Shattuck DG 2nd, Crandall CS. Transgender and Gender-Nonconforming Patients in the Emergency Department: What Physicians Know, Think, and Do. Ann Emerg Med. 2018 Feb;71(2):183-188.e1. doi: 10.1016/j.annemergmed.2017.09.042. Epub 2017 Nov 3. PubMed PMID: 29103796.

Podcast #385: Probiotics Sep 28, 2018

Show notes

Author: John Winkler, MD

Educational Pearls:

Probiotics are bacteria that are ingested to promote gut health but recent research casts doubt on their effectiveness.

Recent study suggests that most probiotics that are ingested are killed by stomach acid. Those that remain are not very healthy and are outcompeted by the normal gut flora.

Probiotics should not be given as a one-size-fits-all treatment.

References:

Zmora N, Zilberman-Schapira G, Suez J, Mor U, Dori-Bachash M, Bashiardes S, Kotler E, Zur M, Regev-Lehavi D, Brik RB, Federici S, Cohen Y, Linevsky R, Rothschild D, Moor AE, Ben-Moshe S, Harmelin A, Itzkovitz S, Maharshak N, Shibolet O, Shapiro H, Pevsner-Fischer M, Sharon I, Halpern Z, Segal E, Elinav E. Personalized Gut Mucosal Colonization Resistance to Empiric Probiotics Is Associated with Unique Host and Microbiome Features. Cell. 2018 Sep 6;174(6):1388-1405.e21. doi: 10.1016/j.cell.2018.08.041. PubMed PMID: 30193112.

Podcast #384: Don't stab a PTA? Sep 26, 2018

Show notes

Author: Don Stader, MD

Educational Pearls:

Recent study suggests we may not need to drain uncomplicated peritonsillar abscesses

Patients who received medical therapy alone had no difference in complications and failure compared to those who received surgical drainage plus medical therapy

Medical therapy in study was ceftriaxone, clindamycin, and dexamethasone

Medical therapy was also associated with fewer opioid prescriptions, sore days, and days off from work.

References:

Battaglia A, Burchette R, Hussman J, Silver MA, Martin P, Bernstein P. Comparison of Medical Therapy Alone to Medical Therapy with Surgical Treatment of Peritonsillar Abscess. Otolaryngol Head Neck Surg. 2018 Feb;158(2):280-286. doi: 10.1177/0194599817739277. Epub 2017 Nov 7. PubMed PMID: 29110574.

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