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 #271: Nexus Chest CT Scan Guidelines Nov 13, 2017

Show notes

Author: Chris Holmes, M.D.

Educational Pearls

The nexus chest CT scan rule is based on an 11,000 subject, multicenter study that looked for signs following a trauma that predicted significant findings on subsequent chest CT.
Findings that were associated with abnormal chest CT included: abnormal CXR, distracting injury, chest wall, sternal, thoracic spine or scapular tenderness. Furthermore, a mechanism of injury that includes rapid deceleration was also associated.
If a patient has none of the above findings, then there is only a small chance that there will be an abnormal chest CT.

References: https://www.mdcalc.com/nexus-chest-ct-decision-instrument-ct-imaging

Podcast #270: Wound Botulism Nov 10, 2017

Show notes

Author: Don Stader, M.D.

Educational Pearls

Wound botulism should be considered in patients with cutaneous lesions and neuromuscular weakness.
The toxin produced by clostridium botulinum is the causative agent. It forms spores, so it is very resistant to killing by heat.
It presents with weakness, most often in the extraocular muscles.
Treatment includes wound care and respiratory support. Anti-toxin is rarely used as it is stored at the CDC and must be flown in.

References: Kalka-Moll WM, Aurbach U, Schaumann R, Schwarz R, Seifert H. Wound Botulism in Injection Drug Users. Emerging Infectious Diseases. 2007;13(6):942-943. doi:10.3201/eid1306.061336.

Podcast #269: Tattoo Ink Complications Nov 08, 2017

Show notes

Author: Michael Hunt, M.D.

Educational Pearls

Tattoo ink is applied below the skin, and because of this, they can lead to keloids, granulomas, tetanus, hepatitis B and C, and skin infections.
Tattoo pigment has been found to contain substances like lead, cadmium, chromium, and arsenic; however, there are no long-term studies of the health effects of tattoos.
In one study 14% of inks had ingredients that were banned in cosmetics.
Nanoparticles of tattoo pigment can be found in the lymph nodes, and laser removal can precipitate their spread.
Those with tattoos could experience complications with MRI because of the metal content of the ink.

References: Khunger N, Molpariya A, Khunger A. Complications of Tattoos and Tattoo Removal: Stop and Think Before you ink. Journal of Cutaneous and Aesthetic Surgery. 2015;8(1):30-36. doi:10.4103/0974-2077.155072.

Podcast #268: Poiseuille's Law Nov 06, 2017

Show notes

Author: Dave Rosenberg, M.D.

Educational Pearls

Poiseuille's Law addresses the flow of a fluid through a tube.
Many common ED presentations involve alterations in flow: asthma, MI, ischemic stroke, etc.
According to the law, flow increases with the 4th power of the radius. That is to say, doubling the radius of the tube will increase the flow by 16x.
Therefore, in situations that require re-opening of an anatomic tube (artery, airway), small changes in the size of the opening will result in dramatic effects.

References: https://www.openanesthesia.org/poiseuilles_law_iv_fluids/

Podcast #267: Causes of Very High Lactate Nov 03, 2017

Show notes

Author: Dylan Luyten, M.D.

Educational Pearls

Lactate is a byproduct of anaerobic metabolism, a sign of dying tissue. Dangerous causes of high lactates will not normalize with repeat labs.
Crush injuries, seizures, bowel necrosis, end-stage liver disease, and metformin toxicity are common causes of highly elevated lactate.

References: https://lifeinthefastlane.com/ccc/lactic-acidosis/

Podcast #266: MI in Young Patients Nov 01, 2017

Show notes

Author: John Winkler, M.D.

Educational Pearls

Some risk factors for MI in the young are history of CAD, stimulant drug use, coronary spasm and diabetes.
In those with diffuse ST elevations on EKG, think pericarditis. Troponin will also be elevated.

References: Egred M, Viswanathan G, Davis GK Myocardial infarction in young adults Postgraduate Medical Journal 2005;81:741-745.

Podcast #265: The 2017 Flu Vaccine Oct 30, 2017

Show notes

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist - Emergency Medicine

Educational Pearls

CDC recommends using the inactivated, injectable flu vaccine in those 6 months and older. The live attenuated vaccine is not used because of low efficacy.
Pregnant women should be vaccinated, and can receive the vaccine at any stage of their pregnancy.
The vaccine is contraindicated ONLY in those with a history of a severe anaphylactic reaction to the injection in the past.
Antivirals (oseltamivir, zanamivir) are useful for Flu A and B. Their dosing needs to be adjusted for renal function, and it is contraindicated in those with ESRD who are not receiving dialysis. It should be used for prophylaxis in those with exposure and/or for the very young, very old, morbidly obese, nursing home residents, and those who are immunocompromised. They may be effective as long as 72 hours after symptom onset.

References: https://www.cdc.gov/flu/professionals/index.htm

Podcast #264: Witnessed Cardiac Arrest Oct 27, 2017

Show notes

Author: Aaron Lessen, M.D.

Educational Pearls

For patients with in-hospital cardiac arrest, intubation in the 1st 15 minutes of resuscitation was associated with worse outcomes (mortality, neurologic outcome). This is likely due to cessation of high-quality CPR and defibrillation during the intubation sequence.
In those with an in-hospital, shockable, cardiac arrest, administration of epinephrine before the 2nd defibrillatory shock was associated with worse outcome. This was likely due to the cessation of high-quality CPR.
For in-hospital cardiac arrest, resuscitation should focus on high-quality CPR.

References: Andersen LW, Granfeldt A, Callaway CW, Bradley SM, Soar J, Nolan JP, Kurth T, Donnino MW, for the American Heart Association's Get With The Guidelines–Resuscitation Investigators. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA. 2017;317(5):494–506. doi:10.1001/jama.2016.20165

Podcast #263: Early Antibiotics in Sepsis Oct 25, 2017

Show notes

Educational Pearls

After the first hour, every 1 hour delay in antibiotics in a patient with septic shock patient is associated with a 4% increase in mortality.
In patients with high suspicion for septic shock (fever and hypotension), antibiotics should be initiated ASAP. Rocephin (ceftriaxone) should be used for those with community-acquired sepsis, zosyn for nosocomial or IV-associated sepsis.

References: https://lifeinthefastlane.com/ccc/antibiotic-timing/

Podcast #262: Pertussis Oct 23, 2017

Show notes

Author: Julian Orenstein, M.D.

Educational Pearls

Colorado has a high population of unvaccinated children, and is at increased risk for pertussis outbreaks.
The causative organism is Bordetella pertussis. It causes causes respiratory epithelial necrosis leading to congestion of the bronchioles, leading to cough.
The cough is unique - it is usually a series of expiratory coughs followed by one deep inspiration
The clinical presentation is divided into 3 phases:
- Catarrhal: cough and congestion with low-grade fever and coryza.
- Whooping: characteristic cough.
- Resolution: recovery with persistent cough.
Infants may not get this presentation, but may get apnea and nonspecific cough.
Tongue depressor can be used to elicit cough for diagnosis.

References: Tozzi AE, Pastore Celentano L, Ciofi degli Atti ML, Salmaso S. Diagnosis and management of pertussis. CMAJ : Canadian Medical Association Journal. 2005;172(4):509-515. doi:10.1503/cmaj.1040766.

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