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 #236: Peripheral IJ Access Aug 07, 2017

Show notes

Author: Nick Hatch, M.D.

Educational Pearls

When peripheral or central IV access is difficult, sometimes providers will try to use a peripheral IV setup at an IJ site using US guidance.
Case studies have shown that this method is often successful, with the most common complication being the loss of access.

References: Ash AJ, Raio C. Seldinger Technique for Placement of "Peripheral" Internal Jugular Line: Novel Approach for Emergent Vascular Access. Western Journal of Emergency Medicine. 2016;17(1):81-83. doi:10.5811/westjem.2015.11.28726.

Podcast #235: ER Discharge and Mortality Aug 05, 2017

Show notes

Author: Pete Bakes, M.D.

Educational Pearls

One of the roles of the ER provider is to discharge patients only after life-threatening conditions have been ruled out. However, some patients that are discharged from the ED die within days of their discharge. One recent study sought to investigate the factors and diagnoses associated with death within 7 days of discharge.
This study was a retrospective study in 10 million medicare recipients that presented to the ER over 10 years. They excluded palliative, hospice and SNF patients.
0.12% of these patients died within 7 days of ER discharge. Signs and symptoms such as altered mental status, general malaise and fatigue, and nonspecific dyspnea had relative risks of 3-5 for death following discharge.
Think carefully before discharge in patients with the signs/symptoms above.

References: Obermeyer Ziad, Cohn Brent, Wilson Michael, JenaAnupam B, Cutler David M. Early death after discharge from emergency departments: analysis of national US insurance claims data BMJ 2017;356 :j239

Podcast #234: CIN AEM Study Aug 03, 2017

Show notes

Author: Dylan Luyten, M.D.

Educational Pearls

Around 30% of patients in the ER receive CT imaging, and the sensitivity of CT imaging may be improved with IV contrast. However, contrast is often withheld for fear of contrast-induced nephropathy.
A recent, single-center, retrospective cohort study compared the rates of nephropathy between contrast CT, non-contrast CT, and no CT control patients, and found no differences.
This study confirms what many have believed to be true - that the dangers of modern contrast may be overstated. However, the results should be interpreted with caution, as this was a retrospective, single-center study.

References: Hinson, Jeremiah S. et al.. Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Annals of Emergency Medicine , Volume 69 , Issue 5 , 577 - 586.e4

Podcast #233: Carfentanil Aug 01, 2017

Show notes

Author: Don Stader, M.D. and Rachael Duncan, PharmD BCPS BCCCP

Educational Pearls

Carfentanil is an opioid elephant tranquilizer that can be used recreationally. It is 1000 times stronger than fentanyl, and looks like a white powder.
Healthcare workers must be cautious when carfentanil overdose is suspected, as the drug can be absorbed through caregivers' skin if it is present on the patient's clothes.
Overdose may require large amounts of naloxone, and a drip may be started at a rate equivalent to the bolus dose that the patient responded to. For example, if the patient responded to a 10mg bolus dose of naloxone, he would then be started on a 10mg/hr naloxone drip.

References: https://www.dea.gov/divisions/hq/2016/hq092216.shtml

Podcast #232: HAPE Jul 30, 2017

Show notes

Author: Gretchen Hinson, M.D.

Educational Pearls

High-Altitude Pulmonary Edema (HAPE) is caused when hypoxemia due to low ambient pO2 leads to breakdown and constriction of the pulmonary vasculature leading to edema.
HAPE is very rare under 8000 ft, but common over 10000 ft (6%). Over 18,000 ft the incidence is very high (12-15%).
Symptoms include dyspnea, cough, weakness and chest tightness.
Signs include hypoxemia, crackles, wheezing, central cyanosis, tachypnea and tachycardia.
Drugs that reduce pulmonary resistance have been shown to help, but increased oxygenation and descent are the best treatments.

References: http://emedicine.medscape.com/article/300716-overview

Podcast #231: Esophageal Tearing Jul 28, 2017

Show notes

Author: Jared Scott, M.D.

Educational Pearls

Boerhaave syndrome (aka effort rupture of the esophagus) accounts for 10% of esophageal ruptures and is usually caused by strain during vomiting episodes. It can also be caused by childbirth, seizure, or prolonged coughing or laughing.
Food and water swallowed after the tear end up in the mediastinum, eventually causing infection. Therefore, Boerhaave syndrome is a surgical emergency.
Best diagnostic techniques are CT or endoscopy.
Mallory-Weiss syndrome may present similarly, however it is less serious since it involves only a small tear through the mucosa at the gastroesophageal junction. This can be managed on an outpatient basis with PPI's.

References: https://radiopaedia.org/articles/boerhaave-syndrome

Podcast #230: Concussive Treatment Jul 26, 2017

Show notes

Author: Aaron Lessen, M.D.

Educational Pearls

2 studies this past year looked at pediatric and adolescent patients following a concussion. They found people who returned to activity sooner did better than those who went on "brain rest".
While patients should still follow up with their PCP following a concussion, it is ok for patients to return to physical activity as tolerated.

References: Grool AM, Aglipay M, Momoli F, Meehan WP, Freedman SB, Yeates KO, Gravel J, Gagnon I, Boutis K, Meeuwisse W, Barrowman N, Ledoux A, Osmond MH, Zemek R, for the Pediatric Emergency Research Canada (PERC) Concussion Team. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504-2514. doi:10.1001/jama.2016.17396

Podcast #229: Andrew Jackson Jul 24, 2017

Show notes

Author: Sam Killian, M.D.

Educational Pearls

Andrew Jackson was the 7th president of the USA. He served 2 terms from 1829-1837.
He had had many medical issues during his presidency. He was said to be chronically underweight with rotting teeth. Furthermore, he had chronic infections and lead poisoning from bullets lodged in his arm and chest.
He suffered from smallpox that he contracted while in a British prison during the Revolutionary War.
He died from "dropsy" (CHF).

References: http://www.doctorzebra.com/prez/g07.htm

Podcast #228: BB Guns Jul 22, 2017

Show notes

Author: Jared Scott, M.D.

Educational Pearls

BB gun eye injuries are most common in August and September. They most often happen to males aged 16-17 year old. Around 10% of the BB eye injuries lead to eye loss.
Accidental firearm injury is common in children and is a common cause of mortality. One-third of homes with children have a firearm.
Most accidental pediatric gun injuries happen to young, male children with guns owned by family members. It is important to educate gun owners about proper gun storage.

References: Childhood Firearm Injuries in the United States Katherine A. Fowler, Linda L. Dahlberg, Tadesse Haileyesus, Carmen Gutierrez, Sarah Bacon. Pediatrics Jun 2017, e20163486; DOI: 10.1542/peds.2016-3486

Podcast #227: CPR-Induced Consciousness Jul 20, 2017

Show notes

Author: Nick Hatch, M.D.

Educational Pearls

CPR-induced consciousness is a phenomenon that occurs when someone who was previously unconscious and is undergoing CPR regains consciousness and makes purposeful movements.
Studies have shown that this phenomenon is increasing, likely because of increased quality of CPR.
Many people use a sedative such as ketamine to keep patients unconscious to reduce the psychologic trauma of CPR.
39% of people who survive CPR with good neurologic details remember the process of CPR .

References:

Joshua Pound, P. Richard Verbeek, and Sheldon Cheske. CPR Induced Consciousness During Out-of-Hospital Cardiac Arrest: A Case Report on an Emerging Phenomenon. 2017. Prehospital Emergency Care Vol. 21.

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