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 #253: Total Eclipse of the Eye - Solar Retinopathy Sep 18, 2017

Show notes

Author: Nick Hatch, M.D.

Educational Pearls

Photic or solar retinitis occurs when you stare at the sun. The refractive power of the lens of the eye concentrates the light of the sun on the retina, stimulating the production of free radicals, damaging photoreceptors.
Solar retinitis may present hours-days after light exposure.
Patients will present with patchy loss of vision without pain, since the retina has no pain receptors.
In one study during an eclipse in the UK, of those who initially presented with vision loss due to solar retinitis, 92% recovered full vision.

References: Dobson R. UK hospitals assess eye damage after solar eclipse. BMJ : British Medical Journal. 1999;319(7208):469.

Podcast #252: Mandible Fractures Sep 15, 2017

Show notes

Author: Sam Killian, M.D.

Educational Pearls

The tongue blade test is done for mandible fractures, which make up 40-60% of facial fractures.
The test is done by having the patient bite down on a tongue depressor on one side of the mouth. The provider then tries to snap the tongue depressor. This is repeated on the other side of the mouth. The test is positive if the patient complains of pain before the depressor can be broken on either side.
It has been compared to CT and X-ray and has a similar sensitivity and specificity (95% and 65%, respectively).

References: J. Neiner, et al. Tongue Blade Bite Test Predicts Mandible Fractures. Craniomaxillofac Trauma Reconstr. 2016

Podcast #251: Cyanide Poisoning Sep 13, 2017

Show notes

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

Educational Pearls

Cyanide poisoning is suspected in patients who present with lactic acidosis after being trapped around burning household objects. It affects our ability to metabolize and can quickly lead to CV collapse and death.
Because cyanide blood levels are not quickly available, the diagnosis is made by history and lactic acidosis on ABG.
The cyanokit is the key treatment. It contains hydroxocobalamin, which binds to cyanide so it can be excreted.
One side effect to be aware of is that the cyanokit will turn everything red, including mucous membranes, saliva, urine, and skin. This will interfere with some lab values, so make sure to get labs before administration.

References: Mégarbane B, et al. Antidotal treatment of cyanide poisoning. J Chin Med Assoc. 2003

Podcast #250: Desmopressin Sep 11, 2017

Show notes

Author: Rachael Duncan, PharmD BCPS BCCCP

Educational Pearls

Desmopressin is an ADH mimetic and helps retain water, release von Willibrand Factor (in high doses), and treat diabetes insipidus (in low doses).
It can also be used in renal colic, because it may reduce muscle spasm in the ureters.
The dosing for renal colic is very small (40 micrograms).

References: http://reference.medscape.com/drug/ddavp-stimate-noctiva-desmopressin-342819

Podcast #249: Detecting Pulses Sep 10, 2017

Show notes

Author: Jared Scott, M.D.

Educational Pearls

Overall, medical providers are bad at detecting pulses.
However, only 2% of patients do not have a detectable DP pulse.
In one study, for patients with limb claudication, there was only about 50% agreement on the presence of a DP pulse.

References: Brearley et al. Peripheral pulse palpation: an unreliable physical sign. Annals of the Royal College of Surgeons of England. 1992

Podcast #248: Family Presence During Resuscitation Sep 08, 2017

Show notes

Author: Aaron Lessen, M.D.

Educational Pearls

Traditionally the family is removed from the room during procedures and codes, but recent research shows that family presence may be beneficial.
50% patients want family present during a code.
Family-related outcomes were improved with presence.
There was no change in medical outcomes, and no increased incidence of medicolegal issues.

References: Jabre et al. Family Presence during Cardiopulmonary Resuscitation. NEJM. 2013.

Podcast #249: D-Dimer Sep 06, 2017

Show notes

Author: Michael Hunt, M.D.

Educational Pearls

In the recent YEARS study, investigators checked every patient with suspicion for PE with a D-dimer, using a modified Wells score for risk stratification. The goal of the study was to show that CT scan usage could safely reduced using this screening method.
The Wells Criteria measures they used to stratify risk were: PE mostly likely dx, hemoptysis, and evidence of DVT. If the d-dimer was 1, but the patient had none of the Wells criteria, the patient did not get a CT. If the patient had any of the criteria, but the d-dimer was only 0.5, the patient did not get a CT scan.
The investigators reduced CT usage by 14% using the new criteria, with no significant increase in morbidity and mortality.

References: van der Hulle et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. The Lancet. 2017

Podcast #248: Patent Foramen Ovale Sep 04, 2017

Show notes

Author: Jared Scott, M.D.

Educational Pearls

The foramen ovale (FO) connects the left and right atria to allow oxygenated blood to bypass the developing lungs, it usually closes at birth but for some it remains patent (PFO).
A PFO allows clots to cross from the venous to arterial circulation, increasing the likelihood of stroke.
PFO is present in 25% of general population, present in 50% of those with stroke of unknown cause, and very common those with stroke under 50 years old.
Treat with anticoagulation or surgical correction.

References: http://www.heart.org/HEARTORG/Conditions/More/CardiovascularConditionsofChildhood/Patent-Foramen-Ovale-PFO_UCM_469590_Article.jsp#.WarsZZN95E4

Podcast #247: Are You Listening? - 3 Ear Emergencies You Can't Miss! Sep 02, 2017

Show notes

Author: Don Stader, M.D.

Educational Pearls

Ear pain is a common complaint in adults and kids.
A red, hot, painful ear with involvement of the pinna could indicate perichondritis - an infection of the cartilage that is usually caused by pseudomonas.
A painful, swollen ear with involvement of the mastoid process could be mastoiditis, which needs to be treated with IV antibiotics to avoid cerebellar abscess.
Ear pain with significant drainage and a cranial nerve deficit points to malignant otitis externa, which needs to be treated with IV antibiotics.

References: John W. Ely, Marlan R. Hansen, Elizabeth C. Clark. Diagnosis Of Ear Pain. 2008. American Family Physician.

Podcast #246: Fever in Sepsis Aug 31, 2017

Show notes

Author: Nick Hatch, M.D.

Educational Pearls

A recent observational cohort study found that the biggest predictor for sepsis survival was fever. Those with higher fevers had better outcomes.
Some possible explanations for this finding are that high fevers indicate good immune response or that high fever cued providers to treat sepsis more aggressively.

References: Paul J Young, Rinaldo Bellomo. Fever in Sepsis: is it cool to be hot?. 2014. Critical Care

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