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 # 363: Ketamine for Alcohol Withdrawal Aug 08, 2018

Show notes

Educational Pearls:

Recent study has shown adjunctive ketamine can be useful in setting of alcohol withdrawal.

Ketamine was associated with a decrease in the amount of benzodiazepines needed, likelihood of intubation, and a decrease in ICU length of stay by 3 days.

For patients with benzodiazepine resistance, ketamine was shown to have symptom relief in an hour and decreased rate of benzodiazepine infusion.

References

Pizon A, Lynch M, Benedict N, et al. 2018. Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal. Critical Care Medicine. 46(8):e768-e771.

Shah, P., McDowell, M., Ebisu, R. et al. J. Med. Toxicol. (2018). https://doi.org/10.1007/s13181-018-0662-8

Podcast # 362: Giant Hogweed Aug 06, 2018

Show notes

Author: John Winkler, MD

Educational Pearls:

Tall flowering plant with phototoxic sap

Direct skin contact with the sap can cause the skin to become photosensitive

Severe blisters and even burns can result

References

Diebel, Matthew (18 June 2018). "Giant Hogweed, a Plant That Can Cause Burns and Blindness, Found in Virginia". USA Today.

Podcast # 361: Vertiginous Dizziness Aug 03, 2018

Show notes

Author: Peter Bakes, MD

Educational Pearls:

Important to find out if patients mean dysequilibrium, lightheadedness, or vertigo when patients say they are "dizzy."

Differentiate central vs. peripheral vertigo

Central vertigo typically present with bulbar syndromes (difficulty swallowing, facial nerve palsy) and cerebellar symptoms (ataxia).

Peripheral vertigo typically present with sudden onset vertigo with nausea and vomiting in the absence of bulbar symptoms.

Episodic? BPPV or Meniere's Disease. BPPV has not auditory symptoms and is associated with head position; Meniere's has hearing loss, tinnitus, and ear fullness.

Constant? Neuronitis has no auditory symptoms, while labyrinthitis has associated hearing loss/tinnitus and is associated with a recent infection (OM).

References

Baloh RW. Differentiating between peripheral and central causes of vertigo. Otolaryngol Head Neck Surg 1998; 119:55.

Chase M, Goldstein JN, Selim MH, et al. A prospective pilot study of predictors of acute stroke in emergency department patients with dizziness. Mayo Clin Proc 2014; 89:173.

Kerber KA, Brown DL, Lisabeth LD, et al. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 2006; 37:2484.

Podcast # 360: Epidural Abscess Screening Aug 02, 2018

Show notes

Author: Dylan Luyten, MD.

Educational Pearls:

Dangerous causes of back pain: AAA, cauda equina syndrome, epidural abscess.

Young person with back pain needs to be evaluated for injection drug use (major risk factor).

Patient with focal neurologic deficits (FND) require an MRI. Patients without FND can be screened with ESR and CRP. An ESR

Treatment is IV antibiotics and surgical debridement.

References

Davis DP et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain, Journal of Neurosurgery: Spine. 2011. 14:765-770.

Podcast # 359: Normal EKG Jul 31, 2018

Show notes

Author: Sam Killian, MD.

Educational Pearls:

Computer interpretation has a very good negative predictive value of a normal EKG (99%).

Of 222 interpreted as "normal," 13 were deemed to have some abnormality by a cardiologist in a recent study.

Those 13 EKG's were read by 2 ER docs, and only 1 missed interpretation warranted a move from triage to a bed.

References

Katie E. Hughes KE., Scott M. Lewis SM., Laurence Katz and Jonathan Jones Safety of Computer Interpretation of Normal Triage Electrocardiograms. 2017. Academic Emergency Medicine 24(1):120-124. http://onlinelibrary.wiley.com/doi/10.1111/acem.13067/full.

Podcast # 358: Affordable ear drop alternatives Jul 27, 2018

Show notes

Author: Erik Verzemnieks, MD

Educational Pearls:

Otic (ear) specific antibiotic drops can be expensive

Opthalmic (eye) versions are basically identical and can be used as an affordable substitute as many are on the $4 drug lists

But don't do the reverse (don't use ear drops on the eye)

Use caution when administering aminoglycoside if tympanic membrane rupture is present

References

https://tgtfiles.target.com/pharmacy/WCMP02-032536_RxGenericsList_NM7.pdf

http://i.walmart.com/i/if/hmp/fusion/four_dollar_drug_list.pdf

https://www.uptodate.com/contents/external-otitis-treatment

Podcast #357: Local Anesthetic Toxicity Jul 25, 2018

Show notes

Author: Michael Hunt, MD

Educational Pearls:

Toxicity happens from local anesthetics being given too fast, too much, or in the unintended spot

Systemic toxicity manifests first with neurologic symptoms like circumoral numbness, tinnitus, blurred vision, nausea, and even seizures. Severe toxicity can then progress to arrhythmias and cardiac arrest.

Maximum doses of lidocaine: 4 mg/kg; and with epinephrine: 7mg/kg.

Maximum dose of bupivacaine: 2mg/kg; with epinephrine 3mg/kg

Editor note: treat seizures with benzodiazepines and avoid propofol for sedation; severe toxicity can also be treated with a 20% lipid emulsion, though there is debate on its efficacy

References

Dickerson DM, Apfelbaum JL. Local anesthetic systemic toxicity. Aesthet Surg J. 2014 Sep;34(7):1111-9. doi: 10.1177/1090820X14543102.

Neal JM, Mulroy MF, Weinberg GL; American Society of Regional Anesthesia and Pain Medicine.. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8. doi: 10.1097/AAP.0b013e31822e0d8a.

Vasques F, Behr AU, Weinberg G, Ori C, Di Gregorio G. A Review of Local Anesthetic Systemic Toxicity Cases Since Publication of the American Society of Regional Anesthesia Recommendations: To Whom It May Concern. Reg Anesth Pain Med. 2015 Nov-Dec;40(6):698-705. doi: 10.1097/AAP.0000000000000320.

Podcast # 356: Babies can't be born addicted Jul 23, 2018

Show notes

Author: Don Stader, MD.

Educational Pearls:

A baby can be born dependent on opioids but not addicted to them.

Opioid addiction (Opioid Use Disorder) is a disease of mature brains and is characterized by compulsive drug use despite adverse consequences.

Opioid addiction is a disease that affects the reward center of the brain

Pregnant patients struggling with addiction do better when started on buprenorphine or methadone. This treatment will cause opioid withdrawal syndrome in newborns, but not the long term morbidity and mortality of illicit opioids.

References

Gowing L, Farrell MF, Bornemann R, Sullivan LE, Ali R. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database of Systematic Reviews 2011, Issue 8: CD004145. DOI: 10.1002/14651858.CD004145.pub4.

Volkow ND, Koob GF, McLellan AT ( 2016). "Neurobiologic Advances from the Brain Disease Model of Addiction." New England Journal of Medicine. 374 (4): 363–371.

Podcast #355: Syphilis Jul 20, 2018

Show notes

Author: Aaron Lessen, MD

Educational Pearls:

Re-emerging STI.

Progresses through distinct phases if untreated:

Primary syphilis: frequently overlooked because initial chancre is painless.

Secondary syphilis: viral syndrome, rash on trunk, palms, and soles.

Latent syphilis: asymptomatic period, lasting 5-20 years.

Tertiary syphilis: includes neurosyphilis (dementia, encephalitis, etc.) and cardiovascular syphilis (aortitis, etc).

Treatment penicillin G 2.4 million units once for primary or secondary treatment; once weekly for 3 weeks for latent/tertiary.

References

Mattei, P., Beachkofsky, T., Gilson, R., Wisco, O. Syphilis: A reemerging infection. 2012. American Family Physician., 86(5), 433-440.

Podcast # 354: Hematometra Jul 18, 2018

Show notes

Author: Sam Killian, MD

Educational Pearls:

Hematometra: uterus filled with blood due to obstruction of outflow tract.
Most commonly a result congenital abnormalities (imperforate hymen, transverse vaginal septum, etc.) but can be acquired due to cervical stenosis, intrauterine adhesions, neoplasms, and post-surgical scarring.
Symptoms include: pain, abnormal bleeding, enlarged uterus
Diagnosis: commonly achieved by ultrasound and physical exam.
Treatment is surgical (cervical dilatation, hysteroscopy, etc.).

References

U Nayak A, Swarup A, G S J, N S. Hematometra and acute abdomen. Journal of Emergencies, Trauma and Shock. 2010;3(2):191-192. doi:10.4103/0974-2700.62117.

Kotter HC, Weingrow D, Canders CP. Hematometrocolpos in a Pubescent Girl with Abdominal Pain. Clinical Practice and Cases in Emergency Medicine. 2017;1(3):218-220. doi:10.5811/cpcem.2017.3.33369.

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