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 #333 - TBI Prognosticators May 23, 2018

Show notes

Author: Michael Hunt, MD

Educational Pearls:

Studies have shown that patients with decreasing GCS scores have worse outcomes, however GCS of 4 has worse outcome than GCS 3.

Alternative scoring system is the GCS-P score which is GCS score - number of non-reactive pupils.

GCS3 50% mortality 70% poor outcome at 6 months; GCS-P of 1 had mortality 74% and poor outcome at about 90% at 6 months.

GCS-P score is a better prognostic indicator than GCS score.

References:

Han J, et al (2014). External validation of the CRASH and IMPACT prognostic models in severe traumatic brain injury. Journal of Neurotrauma. 31(13):1146-52.

Maas AI, et al. (2007). Prognosis and clinical trial design in traumatic brain injury: the IMPACT study. Journal of Neurotrauma. 24(2):232-8.

The CRASH trial management group, & the CRASH trial collaborators. (2001). The CRASH trial protocol (Corticosteroid randomisation after significant head injury) [ISRCTN74459797]. BMC Emergency Medicine, 1, 1. http://doi.org/10.1186/1471-227X-1-1.

Podcast #332 - Door To Furosemide Time May 21, 2018

Show notes

Author: Nick Hatch, MD

Educational Pearls:

Recent study argues that CHF patients receiving furosemide within 60 minutes of arrival had a lower in-hospital mortality than those receiving it after (2.3% vs. 6.0%, p=0.002).

Flaw in study is that there were significant baseline differences between groups.

References:

Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. JACC 2017. PMID: 28641794

Podcast # 331: Oral Rehydration Therapy (ORT) May 19, 2018

Show notes

Author: Nick Hatch, MD

Educational Pearls:

The sodium-glucose cotransporter in the gut is essential for rehydration.

Oral rehydration therapies require an equimolar concentration of glucose and sodium to be effective.

ORT has saved millions of lives globally.

Consider using ORT in patients with dehydration. Especially useful in resource limited settings.

References:

Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ. 2000; 78:1246.

Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am. 2018. 36(2):259-273. doi: 10.1016/j.emc.2017.12.004.

Podcast # 330: Behcet Disease May 17, 2018

Show notes

Author: Nick Hatch, MD

Educational Pearls:

Behcet Disease is an autoimmune disease that can affect any organ system.

Typical symptoms include recurrent oral and genital ulcers, but more concerning features include skin rashes, ocular problems, and strokes.

Patients with Behcet disease with hypotension should have low threshold for giving steroids.

References:

Arlt W, Allolio B. Adrenal insufficiency. Lancet, 2003; 361:1881.

Sakane T, Takeno M, Suzuki N, Inaba G. Behçet's disease. New England Journal of Medicine. 1999; 341:1284.

Podcast # 329: Hypokalemic Periodic Paralysis May 15, 2018

Show notes

Author: Dylan Luyten , MD

Educational Pearls:

Rare autosomal dominant condition that is often misdiagnosed as a psychiatric illness.

Presents as profound muscle weakness with frank paralysis that is often precipitated by vigorous exercise, high carb diet, high sodium load, or by high temperatures.

Supplemental potassium can rapidly reverse symptoms.

Important to rule out thyrotoxicosis (get a TSH!).

Prevention is key: adhering to a low carb and low sodium diet with supplemental potassium can help prevent episodes.

References:

Vicart S, Sternberg D, Arzel-Hézode M, et al. Hypokalemic Periodic Paralysis. 2002 Apr 30 [Updated 2014 Jul 31]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1338/?report=classic

Statland JM, Fontaine B, Hanna MG, et al. Review of the Diagnosis and Treatment of Periodic Paralysis. Muscle & Nerve. 2018;57(4):522-530. doi:10.1002/mus.26009.

Podcast # 328: Sleep Deprivation May 11, 2018

Show notes

Author: Sam Killian, MD

Educational Pearls:

Insufficient sleep and disrupted circadian rhythms are a major health problem today

Millions of dollars, thousands of deaths, and millions of injuries are related to sleep deprivation every year
56 billion dollars - 24,000 deaths - 2.5 million disabiling injuries related to a sleep-type deprivation
Exxon valdez, challanger, chyrnobel linked to sleep deprivation- at least partially
Data has shown that in the Spring (when people lose an hour of sleep) there were 8% more traffic accidents on the Monday immediately after daylight savings. Conversely, in the Fall (when people gain an hour of sleep), there were 8% fewer traffic accidents on the Monday immediately after daylight savings.
Studies have also shown an increased risk of myocardial infarction in Spring immediately after daylight savings, and a decreased risk of myocardial infarction in the Fall immediately after daylight savings.

References:

Corren S. Traffic Accidents and Daylight Saving Time. New England Journal of Medicine. 1996;335(5):355-357. doi:10.1056/nejm199608013350517

Janszky I, Ljung R. Shifts to and from Daylight Saving Time and Incidence of Myocardial Infarction. New England Journal of Medicine. 2008;359(18):1966-1968. doi:10.1056/nejmc0807104.

Podcast # 327: No More Hemoccults May 09, 2018

Show notes

Author: Don Stader, MD

Educational Pearls:

The use of fecal occult blood tests is falling out of favor in emergency departments

These tests have strong evidence suggesting their efficacy in colon cancer screening but clinical significance in ED is limited

They have relatively high false positive and false negative rates

Small/microscopic bleeding are often not clinically significant in the ED but can lead to increased costs from over-testing and other harms from fecal occult blood testing

References:

Gupta A, Tang Z, Agrawal D. Eliminating In-Hospital Fecal Occult Blood Testing: Our Experience with Disinvestment. American Journal of Medicine. (2018). 10.1016/j.amjmed.2018.03.002

Podcast # 326: Valley Fever May 07, 2018

Show notes

Author: Michael Hunt, MD

Educational Pearls:

Valley fever is a fungal infection known as Coccidiomycosis that can present with vague symptoms like cough, fever, myalgias.

A thorough history is critical to the diagnosis. Disease is localized to the Southwestern US (California, New Mexico, Arizona, Nevada, Utah) and parts of Central/South America.

Disease is caused by inhaling fungal spores which damage the lung. Rarely, the disease can disseminate and cause infections that require systemic anti fungal therapy.

References:

Centers for Disease Control and Prevention (CDC). Increase in reported coccidioidomycosis--United States, 1998-2011. MMWR Morb Mortal Wkly Rep 2013; 62:217.

Saubolle MA, McKellar PP, Sussland D. (2007). Epidemiologic, clinical, and diagnostic aspects of coccidioidomycosis. Journal of Clinical Microbiology. 45:26.

Taylor AB, Briney AK. (1949). Observations on primary coccidioidomycosis. Annals of Internal Medicine. 30:1224.

Podcast #325: Vaping and Pneumonia May 04, 2018

Show notes

Author: Sam Killian, MD

Educational Pearls:

Being exposed to E-cigarette vapor may increase risk of pneumonia.
Recent study has shown e-cigarette vapor increases quantities of Platelet-activating-receptor factor in epithelial cells, which may aid pneumococcal bacteria in entering pneumocytes.

References:

Miyashita L, et al. (2018). E-cigarette vapour enhances pneumococcal adherence to airway epithelial cells. The European Respiratory Journal. 7;51(2).

Podcast #324: Superwarfarin May 02, 2018

Show notes

Author: Rachel Beham, PharmD

Educational Pearls:

Some synthetic cannabinoids have been contaminated with Brodifacoum. Brodifacoum is a Vitamin K antagonist and can present with a severe coagulopathy.

Brodifacoum is commonly known as "superwarfarin" and has a very long half life of 120+ days.

Check PT/INR in patients with a bleeding diathesis in setting of synthetic cannabinoid use.

Treatment is activated charcoal and large doses of Vitamin K (10mg Q6H for months).

References:

Lipton R.A.; Klass E.M. (1984). "Human ingestion of a 'superwarfarin' rodenticide resulting in a prolonged anticoagulant effect". JAMA. 252: 3004–3005.

La Rosa F; Clarke S; Lefkowitz J. B. (1997). "Brodifacoum intoxication with marijuana smoking". Archives of Pathology & Laboratory Medicine. 121: 67–69

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