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 #200: Non-traumatic Back Pain May 06, 2017

Show notes

Author: Don Stader M.D.

Educational Pearls:

Non-traumatic back pain is a very common complaint in the Emergency Department.
Conditions that can manifest with back pain include: ruptured abdominal aortic aneurysm, retroperitoneal bleeding, cauda equina syndrome, epidural abscess or cancer.
Patients with cauda equina syndrome or epidural abscess prefer to sit forward, while people with disc issues tend to sit upright.

References: https://emergencymedicinecases.com/episode-26-low-back-pain-emergencies/

Podcast #199: Prolonged QT with Zofran May 04, 2017

Show notes

Author: Arthur Lessen M.D.

Educational Pearls:

Zofran (ondansetron) is generally safe to use for the treatment of nausea and vomiting. However, it can prolong the QT interval and increase the chance for torsades.

Low doses of Zofran are not likely to be an issue. However, when multiple doses are given, especially in the setting of a preexisting LQTS, clinical concern should be raised.

When giving Zofran to a patient with an increased risk for torsades, consider continuous cardiac monitoring or an alternate anti-emetic.

References: https://www.fda.gov/Drugs/DrugSafety/ucm310190.htm

Podcast #198: Imodium May 02, 2017

Show notes

Author: Aaron Lessen M.D.

Educational Pearls:

Imodium (loperamide) is a mu-opioid receptor agonist. Traditionally, it is used as an anti-diarrheal. It is also abused recreationally for an opioid high and to self-treat opioid withdrawal.
40 or more pills are often ingested. People often co-ingest with cimetidine to potentiate the desired effects.
Patients will present with opioid overdose symptoms (narrow pupils, respiratory depression).
Narcan is effective in reversing an overdose of Imodium.
Imodium prolongs QT and predisposes to Torsades, so monitor rhythm and then treat like any other opioid OD.

References: http://www.tandfonline.com/doi/abs/10.3109/15563650.2016.1159310

Podcast #197: Ashman Phenomenon Apr 30, 2017

Show notes

Author: Dylan Luyten M.D.

Educational Pearls:

Ashman's Phenomenon occurs in the setting atrial fibrillation and mimics ventricular tachycardia, but is harmless.
On ECG, the pattern of Ashman Phenomenon is a long cycle, followed a short cycle, followed by a complex wide complex beat.
The wide complex beats have right BBB morphology. The long R-R followed by a short R-R leads to conduction down the left bundle branch while the right bundle branch is still in a refractory period.

References: https://lifeinthefastlane.com/ecg-library/atrial-fibrillation/

Podcast #196: DVT and May-Thurner Syndrome Apr 28, 2017

Show notes

Author: Samuel Killian M.D.

Educational Pearls:

Lower extremity DVTs are extremely common. There are more left lower extremity DVT due to anatomical variation.
May-Thurner Syndrome is a form of anatomical variation in which the left iliac artery compresses the left iliac vein.
Anticoagulation may not be sufficient to treat those with May-Thurner syndrome - endovascular stenting may be needed
Patients with with recurrent LLE DVT, especially those in whom anticoagulation fails, should be referred to a specialist.

References: Peters M, Syed RK, Katz M, et al. May-Thurner syndrome: a not so uncommon cause of a common condition. Proceedings (Baylor University Medical Center). 2012;25(3):231-233. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377287/

Podcast #195: How to Properly Inject Heroin Apr 26, 2017

Show notes

Author: Don Stader, M.D

Educational Pearls:

It is important for providers to know how to use IV drugs properly so that they can instruct their patients on how to avoid injury. Heroin use is increasing.
Hepatitis, HIV and infection are possible complications of improper IV drug use
The first step of heroin use is to dissolve the solid heroin in water using heat - a spoon and lighter are often used for this step. Next, the heroin is drawn into the syringe through a filter (cotton is often used).
Heroin concentration often varies widely - counsel patients to test their heroin first.
Sterility of the needle, water, cooker, cotton and syringe is paramount. Refer patients to a needle exchange program where they can get clean supplies.
Hepatitis C can live outside the body for 4 days - NEVER share ANY supplies.
Sterile procedure is important - needles should not be licked.

References: http://drugsense.org/flyers/10_tips_for_safer_use.pdf

Podcast #194: Atruamatic ICH Apr 24, 2017

Show notes

Author: Peter Bakes, M.D

Educational Pearls

Intracerebral hemorrhage is an intracranial bleed within the brain tissue or ventricles.
Subarachnoid aneurysm causes about 50% of all ICH.
Amyloid deposition can lead to ICH in elderly patients.
Hypertension is another common cause of atraumatic ICH, commonly leading to pontine, cerebellar, or basal ganglial bleeding. Bleeding in other locations is suggestive of a different etiology.
ICH will often present with depressed mental status, but specifically a patient with a systolic BP > 220 is suggestive of hypertensive ICH.
CT is the first diagnostic step. CTA should be considered when the bleeding is in an atypical area. Significant edema on imaging can be suggestive of a tumor.
Treatment should include hemostatic measures and BP control. Transfuse platelets if necessary and reverse any anticoagulation. BP target is

References: Sahni R, Weinberger J. Management of intracerebral hemorrhage. Vascular Health and Risk Management. 2007;3(5):701-709. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291314/

Podcast #193: The Quick Wee Apr 22, 2017

Show notes

Author: JP Brewer M.D.

Educational Pearls:

The "Quick Wee" was a method to get urine out of infants who need to have a UA in the Emergency Department.
A randomized-controlled experiment was done with 350 infants between the ages of 1 to 12 months.
The "Quick Wee" method is taking a sterile saline gauze with cool saline and rubbing it over the suprapubic abdomen for five minutes. The results were significant, with 31% in the treatment group voided after five minutes, 12% in the control group voided after five minutes.

References: http://www.bmj.com/content/357/bmj.j1341

Podcast #192: Back Fat Hernia Apr 20, 2017

Show notes

Author: Jared Scott M.D.

Educational Pearls:

There are two anatomical triangles on the back, the inferior lumbar triangle and the superior lumbar triangle.
Herniation occurs whenever something moves to a place where it is not supposed to be, often through a fascial weakness.
A "back hernia" can happen when the contents of of the abdominal cavity herniate into the back, usually through the superior lumbar triangle. This is also known as a Grynfeltt-Lesshaft hernia.
Back hernias can be traumatic or congenital.
These hernias are typically treated surgically.

References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959346/

Podcast #191: Blunt Cervical Trauma Apr 18, 2017

Show notes

Author: Chris Holmes M.D.

Educational Pearls:

Mechanism of injury involves hyperextension/hyperflexion
Pathophysiology: inside of the arteries in the neck becomes disrupted, similar to a dissection. This is thrombogenic and leads to cerebral infarction
Neurologic deficit is common.
Other risk factors include facial fracture and cervical-spine fracture.
Treat with anticoagulation - aspirin or other antiplatelet agents are appropriate.
Increase clinical suspicion when patient presents with neurological deficit and has a negative CT.

References: https://www.east.org/education/practice-management-guidelines/blunt-cerebrovascular-injury

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