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 #313: Flu Screening Apr 02, 2018

Show notes

Author: Dr. Peter Bakes

Educational Pearls:

High risk patients: underlying lung disease, immunocompromised, extremes of age (65), underlying cardiac/renal/neurologic disease, and pregnant women
Testing: RT-PCR (RNA based test that is both sensitive and specific)
Workup: comorbidities dictate whether or not they are screened; CXR indicated in high risk patients with respiratory symptoms
Morbidity from flu comes from secondary pneumonia, sepsis, and septic shock
Treatment options are Tamiflu and Relenza (Relenza is contraindicated in patients with lung disease)
High risk patients see average of 2.5 days shortening of illness and a decrease in illness severity. Low risk patients see average of 1.5 days shortening of illness.

References:

https://www.cdc.gov/flu/about/disease/high_risk.htm

Binnicker MJ, Espy MJ, Irish CL, Vetter EA. Direct Detection of Influenza A and B Viruses in Less Than 20 Minutes Using a Commercially Available Rapid PCR Assay. J Clin Microbiol. 2015 Jul; 53(7): 2353-4.

Longo, Dan L. (2012). "187: Influenza". Harrison's principles of internal medicine (18th ed.). New York: McGraw-Hill. ISBN 9780071748896.

Podcast #312: SCIWORA Mar 30, 2018

Show notes

Author: Sam Killian, M.D.

Educational Pearls:

Spinal cord injury without radiographic abnormality (SCIWORA) is a diagnosis defined as traumatic injury to spine with clinical sx of traumatic myelopathy (paraplegia, paresthesias, FND) without radiographic abnormalities.

Term was established in 1970's before MRI and accounted for about 15% of injuries at the time (mainly children). Today SCIWORA accounts for about 10% of spinal injuries.

Belief is that injury causes subtle movement of the spinal cord from its natural position with resultant contusion or ischemia with subsequent deficits.

Treatment involves prolonged immobilization (up to 12 weeks).

References:

Walecki, J. (2014). Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) – Clinical and Radiological Aspects. Polish Journal of Radiology,79, 461-464. doi:10.12659/pjr.890944

Podcast #311: Recurrence of Seizures in Pediatrics Mar 28, 2018

Show notes

Author: Aaron Lessen, M.D.

Educational Pearls:

Recurrence rate for first time unprovoked seizures - 5% after 48 hours, 14% at 2 weeks , 30% after 4 months.
Higher risk for recurrence: age under 3; patients with multiple seizures at initial presentation, focal neurologic findings on initial presentation.
Useful for counseling patients and recommending follow up.

References:

Shinnar S, Berg AT, Moshé SL, et al. Risk of seizure recurrence following a first unprovoked seizure in childhood: a prospective study. Pediatrics 1990; 85:1076.

Podcast #310: Bicarb in DKA Mar 26, 2018

Show notes

Author: Gretchen Hinson, M.D.

Educational Pearls:

Controversial topic.
Pathophysiology - acidosis leads to an extracellular potassium shift. Patients in DKA will be intracellularly potassium deplete, but will have a falsely normal/elevated serum potassium.
3 risk of giving bicarb in DKA - alkalosis will drive potassium intracellularly but can overshoot (hypokalemia) and increase risk of arrhythmias; bicarb slows clearance of ketones and will transiently increase their precursors; bicarb can cause elevated CSF acidosis.
3 instances when appropriate to give bicarb in DKA: DKA in arrest; hyperkalemic in DKA with arrhythmia; fluid and vasopressor refractory hypotension.

References:

Bratton, S. L., & Krane, E. J. (1992). Diabetic Ketoacidosis: Pathophysiology, Management and Complications. Journal of Intensive Care Medicine, 7(4), 199-211. doi:10.1177/088506669200700407

Chua, H., Schneider, A., & Bellomo, R. (2011). Bicarbonate in diabetic ketoacidosis - a systematic review. Annals of Intensive Care, 1(1), 23. doi:10.1186/2110-5820-1-23

Podcast #309: Return Visits to the ED for UTI Mar 23, 2018

Show notes

Author: Alicia Oberle, MD

Educational Pearls:

Recent study has shown risk factors for return included patients at high risk for resistance (nursing home, obstructive uropathy), patient where diagnogsis of pyelonephritis was missed, but the biggest risk factor was the existence of bug-drug mismatches.

Cephalexin (Keflex) was associated with highest rate of return, while nitrofurantoin (Macrobid) was associated with lowest return rate.

Recommendation is to continue to detect between pyelonephritis and cystitis, broaden coverage for patients with complications, and utilize your facilities antibiogram.

References:

Jorgensen S, et al. ( 2018). Risk factors for early return visits to the emergency department in patients with urinary tract infection. American Journal of Emergency Medicine. 36(1):12-17

Podcast #308: Ultrasound in Cardiac Arrest Mar 21, 2018

Show notes

Author: Aaron Lessen, M.D.

Educational Pearls:

There is currently debate within the medical community about what constitutes cardiac activity on ultrasound in the setting of cardiac arrest. A recent study has shown there providers looking at the same clips from an echo will disagree about what constitutes cardiac activity.

Some of the confusion stems from movement that is not cardiac in etiology. For example, some alvular movement can be due to IV fluids and some cardiac motion can be due to the patient being bagged.

Cardiac activity is defined as "Any intrinsic motion of the myocardium." However, even if this is present, it is important to ask if it clinically significant cardiac activity.

Despite disagreement, ultrasound can be useful for clinical decision making.

References:

Gaspari R et al. (2016) Emergency Department Point-Of-Care Ultrasound in Out-Of-Hospital and in-ED Cardiac Arrest. Resuscitation; 109: 33 – 39.

Hu K et al. (2017) Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med.

Podcast #307: Guillain-Barre Syndrome Mar 19, 2018

Show notes

Author: Peter Bakes, M.D.

Educational Pearls:

Rare disease with 1-2 patients out of 100,000. About 60% of patients report a preceding diarrheal illness and classically presents with an ascending motor weakness.

Pathophysiology is likely due to molecular mimicry where the immune system creates antibodies against a pathogen (C. jejuni ) which appears similar to the myelin of peripheral nerves resulting in autoimmune demyelination.

Diagnosis is made by clinical presentation +/- a spinal tap with a characteristic high protein count but without cells.

Treatment is IVIG or plasmapharesis. It is important to monitor respiratory function because about 15% of patients progress to respiratory failure.

References:

Sejvar, James J.; Baughman, Andrew L.; Wise, Matthew; Morgan, Oliver W. (2011). "Population incidence of Guillain–Barré syndrome: a systematic review and meta-analysis"

van den Berg, Bianca; Walgaard, Christa; Drenthen, Judith; Fokke, Christiaan; Jacobs, Bart C.; van Doorn, Pieter A. (15 July 2014). "Guillain–Barré syndrome: pathogenesis, diagnosis, treatment and prognosis". Nature Reviews Neurology. 10 (8): 469–482.

Yuki, Nobuhiro; Hartung, Hans-Peter (14 June 2012). "Guillain–Barré Syndrome". New England Journal of Medicine. 366 (24): 2294–2304.

Podcast #306: Tramadol Drama Mar 16, 2018

Show notes

Author: Nick Hatch, M.D.

Educational Pearls

Tramadol acts at multiple receptors and is a partial agonist at the mu opioid receptor, but also blocks reuptake of serotonin and norepinephrine throughout the body among others.

One major side effect to be aware of is that it lowers the seizure threshold.

Useful in setting of pain control in patients with contraindications to NSAIDs who are poor opioid candidates.

Use with caution as it potential for abuse.

References

Hennies HH, Friderichs E, Schneider J (July 1988). "Receptor binding, analgesic and antitussive potency of tramadol and other selected opioids". Arzneimittel-Forschung. 38 (7): 877–80.

"Tramadol Hydrochloride". The American Society of Health-System Pharmacists. Retrieved Dec 1, 2014.

"Withdrawal syndrome and dependence: tramadol too". Prescrire Int. 12 (65): 99–100. 2003

Podcast #305: Stuffers vs. Packers : Drug-Packet Ingestion Mar 14, 2018

Show notes

Author: Aaron Lessen, M.D.

Educational Pearls

A "stuffer" is a term for someone who hastily and conceals a bag of drugs orally/rectally/vaginally in an unplanned situation. A "packer" is someone who is planning to smuggle drugs, and does so in a similar manner.

"Stuffers"are more likely to have the drug container open up in their system, while packers tend to have more reliable containment, but typically have larger quantities on-board.

Be on look out for symptoms associated with the drug's exposure (drug dependent) as well as mechanical symptoms (perforation; obstruction).

If suspicious, order CT as X-rays underestimate severity.

Management: treat symptoms of intoxication appropriately, observe if packets are intact, consider surgery/endoscopy if necessary.

References

Dueñas-Laita A, Nogué S, Burillo-Putze G (2004). "Body packing". New England Journal of Medicine. 350 (12): 1260–1

Hergan K, Kofler K, Oser W (2004). "Drug smuggling by body packing: what radiologists should know about it". Eur Radiology. 14 (4): 736–42.

Traub SJ, Hoffman RS, Nelson LS (2003). "Body packing—the internal concealment of illicit drugs". New England Journal of Medicine. 349 (26): 2519–26.

Podcast #304: Nostalgia Mar 12, 2018

Show notes

Author: Dylan Luyten, MD

Educational Pearls

Johannes Hoffer coined term Nostalgia in 1688 in his medical dissertation.

Nostalgia was a formal medical diagnosis, and one that dates back to 17th century when soldiers had longing for home and melancholy with a constellation of symptoms including lethargy, sadness, disturbed sleep, heart palpitations, GI complaints, and/or skin findings for which the only cure was to return home.

In the civil war, over 5000 soldiers were given medical leave for nostalgia.

Always remember to view your patient in the appropriate context (psychosocial, cultural, historical, etc.)

References

Beck, J. (2013, August 14). When Nostalgia Was a Disease. Retrieved March 08, 2018, from https://www.theatlantic.com/health/archive/2013/08/when-nostalgia-was-a-disease/278648/

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