Shows
Emergency Medical MinuteEpisode 966: Acetaminophen ToxicityContributor: Jorge Chalit-Hernandez, OMS4 Educational Pearls: What is the toxic dose of acetaminophen? 7.5 grams, in an adult. The safe daily limit is 4 grams in an adult with a normally functioning liver. This is equivalent to fifteen 500mg pills. What are the symptoms of acetaminophen toxicity? First 24 hours, symptoms are non-specific e.g. nausea, vomiting, lack of appetite. Can also be asymptomatic. 24-72 hours, hepatotoxicity occurs (causing yellow skin, pruritus, abdominal pain, bleeding, and confusion) Fulminant liver failure at 72-96 hours Liver function tests (LFTs) peak at 72-96 hours. When would you give activated charcoal? Within 4 hours...
2025-07-2103 minEmergency Medical MinuteEpisode 964: Ketamine & Midazolam for Prehospital Seizure ManagementContributor: Aaron Lessen, MD Educational Pearls: Prehospital seizures are typically managed with intramuscular midazolam (Versed) Seizures theoretically involve the NMDA pathway, and ketamine is a potent NMDA antagonist A recent retrospective cohort study analyzed a Florida EMS protocol that uses ketamine in seizures refractory to midazolam One group received two doses of midazolam for seizure control The other group received a dose of midazolam followed by a dose of ketamine After matching, 82% of the midazolam-only group patients had resolution of convulsions prior to ED arrival 94.4% of patients in the midazolam + ketamine group experienced resolution Absolute difference...
2025-07-0704 minEmergency Medical MinuteEpisode 963: Antihypertensives and Emergency Room ConsiderationsContributor: Alec Coston, MD Educational Pearls: For patients presenting to the emergency room with hypertension, clinicians should determine if it is isolated and uncomplicated, or involves comorbidities with more complex underlying pathophysiology. For uncomplicated and isolated hypertension, first-line treatment is thiazide diuretics. How do thiazide diuretics work to treat hypertension? Thiazide diuretics work by blocking sodium and chloride resorption in the kidneys. "Where sodium goes, water follows," thus promoting diuresis and lowering blood pressure. Examples of thiazide diuretics and their benefits? Hydrochlorothiazide (HCTZ): First-line medication in uncomplicated and...
2025-06-3004 minEmergency Medical MinuteEpisode 962: HEART ScoreContributor: Taylor Lynch, MD Educational Pearls: How do we risk-stratify chest-pain patients? One option is the HEART score This score predicts a patient's 6-week risk of a major adverse cardiac event. Ex. Cath procedure, CABG, PCI, death H stands for History Ask 1) Was the patient diaphoretic? 2) Did they have nausea and/or vomiting? 3) Did the pain radiate down the right or left arm? 4) Was it exertional? Yes to one = one point. Two or more = two points. E stands for EKG One point for left ventricular hypertrophy, t-wave inversions, new bundle-branch blocks. No points for first...
2025-06-2304 minEmergency Medical MinuteEpisode 961: Cell Phone SignContributor: Aaron Lessen, MD Educational Pearls: A prospective study at the Mayo Clinic Rochester was conducted to examine whether patients actively using their phones on initial assessment in the ED was associated with higher discharge rates The study included 292 patients, and only about 15% of patients were on their phone The patients on their phone tended to be a younger demographic Scribes were trained to record the data during their shifts The results did show that patients on their phone have a higher rate of discharge 94% chance of discharge if the patient is on their phone 64% chance of...
2025-06-1601 minEmergency Medical MinuteEpisode 960: Frank's Sign - A Marker for Coronary Artery DiseaseContributor: Travis Barlock MD Educational Pearls Frank's sign is a curious physical exam finding first described in the literature in 1973 Bilateral earlobe creases are recognized as a marker of coronary artery disease and cerebrovascular disease Some studies have found an increase in all-cause mortality in patients with bilateral diagonal earlobe creases The pathophysiology is still not fully understood One 2020 study found histopathological changes associated with diagonal earlobe creases, potentially linking them via a model of hypoxia/reoxygenation References Elliott WJ, Karrison T. Increased all-cause and cardiac morbidity and mortality associated with the diagonal earlobe crease...
2025-06-0901 minEmergency Medical MinuteEpisode 959: The KLM Flight Disaster and Lessons in Healthcare CommunicationContributor: Taylor Lynch, MD Educational Pearls: The KLM Flight Disaster, also known as the Tenerife Airport Disaster, occurred on 27 March 1977. It involved the collision of two Boeing 747 passenger jets from KLM and Pan Am Airlines, resulting in 583 fatalities. What fell through the cracks to cause this incident? The captain of the KLM flight believed he had received clearance from air traffic control to take off, when in fact he had not. This captain was one of the most senior pilots in the organization, and the culture often saw senior pilots as infallible and n...
2025-06-0206 minEmergency Medical MinuteEpisode 958: Intranasal FentanylContributor: Aaron Lessen, MD Educational Pearls: How do we take care of kids in severe pain? There are many non-pharmacologic options for pain (i.e. ice, elevation) as well as more conventional medication options (i.e. acetaminophen, NSAIDS) but in severe pain stronger medications might be indicated. These stronger medications include options such as IV morphine, a subdissociative dose of ketamine, as well as intranasal fentanyl. Intranasal fentanyl has many advantages: Studies have shown it might be more effective early on in controlling pain, as in the first 15-20 minutes after administration, and then becomes...
2025-05-2601 minEmergency Medical MinuteEpisode 957: Cardiac AsthmaContributor: Travis Barlock, MD Educational Pearls: Wheezing is classically heard in asthma and COPD, but it can be the result of a wide range of processes that cause airflow limitation Narrowed bronchioles lead to turbulent airflow → creates the wheezing Crackles (rales) suggest pulmonary edema which is often due to heart failure Approximately 35% of heart failure patients have bronchial edema, which can also produce wheezing COPD and heart failure can coexist in a patient, and both of these diseases can cause wheezing It's vital to differentiate whether the wheezing is due to the patient's COPD or their heart fa...
2025-05-1903 minEmergency Medical MinuteEpisode 956: Psychedelics and Risk of SchizophreniaContributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Psychedelics are being studied for their therapeutic effects in mental illnesses, including major depressive disorder, post-traumatic stress disorder, anxiety, and many others Classic psychedelics include compounds like psilocybin, LSD, and ayahuasca MDMA and ketamine are often included in psychedelic research, but have a different mechanism of action than the others Their mechanism of action involves agonism of the 5HT2A receptor, among others Given their resurgence, there is an increase in recreational use of these substances A recent study assessed the risks of recreational users developing subsequent psychotic disorders Individuals who...
2025-05-1202 minEmergency Medical MinuteEpisode 955: Cardiac Effects of COVID-19Contributor: Ricky Dhaliwal, MD Educational Pearls: What factors are considered in a COVID-19 infection? The viral load: Understood as the impact of SARS-CoV-2 viral particles infecting host cell tissue itself (utilizing ACE-2 receptors). Pro-Inflammatory Response: Post-infection, the body's downstream systemic cytokine release (can be both normal or hyperactive, aka "cytokine storm"). What cardiac impacts have been observed with COVID-19? Arrhythmias: The mechanism of COVID-19 infection and arrhythmias is believed to be multifactorial. However, evidence suggests T-cell-mediated toxicity and cytokine storm may contribute to cardiac myocyte damage, precipitating proarrhythmias instead of direct viral entry...
2025-05-0504 minEmergency Medical MinuteEpisode 954: Combo Rescue Inhalers - New GuidelinesContributor: Aaron Lessen, MD Educational Pearls: What is a Rescue Inhaler? A rescue inhaler is a medication for people with asthma to quickly reverse the symptoms of an asthma attack. Historically albuterol (Short Acting Beta Agonist (SABA)) monotherapy has been the mainstay rescue inhaler. This is because albuterol works fast and is relatively cheap. \n\n What are Combination Rescue Inhalers? Combination rescue inhalers contain a fast-acting bronchodilator as well as an inhaled corticosteroid (ICS) The steroid helps to reduce some of the chronic airway i...
2025-04-3003 minEmergency Medical MinuteEpisode 953: Penicillin AllergiesContributor: Geoff Hogan MD Educational Pearls: Penicillin allergies are relatively uncommon despite their frequent reports 10% of the population reports a penicillin allergy but only 5% of these cases are clinically significant 90-95% of patients may tolerate a rechallenge after appropriate allergy evaluation Penicillin Allergy Decision Rule (PEN-FAST) on MD Calc Useful tool to assess patients for penicillin allergies Five years or less since reaction = 2 points (even if unknown) Anaphylaxis or angioedema OR Severe cutaneous reaction = 2 points Treatment required for reaction (e.g. e...
2025-04-2102 minEmergency Medical MinuteEpisode 950: Ultrasound Pulse Check During Cardiac ArrestContributor: Aaron Lessen, MD Educational Pearls: Point-of-care ultrasound (POCUS) is used to assess cardiac activity during cardiac arrest and can identify potential reversible causes such as pericardial tamponade Ultrasound could be beneficial in another way during cardiac arrest as well: pulse checks Manual palpation for detecting pulses is imperfect, with false positives and negatives Doppler ultrasound can be used as an adjunct or replacement to manual palpation for improved accuracy Options for Doppler ultrasound of carotid or femoral pulses during cardiac arrest: Visualize arterial pulsation
2025-03-3102 minEmergency Medical MinuteEpisode 949: Hoover's SignContributor: Travis Barlock, MD Educational Pearls: What is Hoover's sign used to identify? This physical exam maneuver differentiates between organic vs. functional (previously known as psychogenic) leg weakness. Organic causes include disease processes such as stroke, MS, spinal cord compression, guillain-barre, ALS, and sciatica, among others In Functional Neurologic Disorder, the dysfunction is in brain signaling, and treatment relies on more of a psychiatric approach How is Hoover's Sign performed? Place your hand under the heel of the unaffected leg and ask the patient to...
2025-03-2401 minEmergency Medical MinuteEpisode 948: CYP Inducers and InhibitorsContributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: CYP enzymes are responsible for the metabolism of many medications, drugs, and other substances CYP3A4 is responsible for the majority Other common ones include CYP2D6 (antidepressants), CYP2E1 (alcohol), and CYP1A2 (cigarettes) CYP inducers lead to reduced concentrations of a particular medication CYP inhibitors effectively increase concentrations of certain medications in the body Examples of CYP inducers Phenobarbital Rifampin Cigarettes St. John's Wort Examples of CYP...
2025-03-1703 minEmergency Medical MinuteEpisode 947: HypercapniaEducational Pearls: Physiologic stimulation of ventilation occurs through changes in levels of: Arterial carbon dioxide (PaCO2) Arterial oxygen (PaO2) Hypercapnia is an elevated level of CO2 in the blood - this primarily drives ventilation Hypoxia is a decreased level of O2 in the body's tissues - the backup drive for ventilation Patients at risk of hypercapnia should maintain an O2 saturation between 88-92% Normal O2 saturation is 95-100% In patients who chronically retain CO2, their main drive for ventilation becomes hypoxia ...
2025-03-1003 minEmergency Medical MinuteEpisode 946: Time to DefibrillationContributor: Aaron Lessen, MD Educational Pearls: Quick background info Cardiac arrest is when the heart stops pumping blood for any reason. This is different from a heart attack in which the heart is still working but the muscle itself is starting to die. One cause of cardiac arrest is when the electrical signals are very disrupted in the heart and start following chaotic patterns such as Ventricular tachycardia (VTach) and Ventricular fibrillation (VFib) One of the only ways to save a person whose heart is in VFib or VTach...
2025-03-0302 minEmergency Medical MinuteEpisode 945: Ketorolac vs. IbuprofenContributor: Ricky Dhaliwal, MD Educational Pearls: Ketorolac and ibuprofen are NSAIDs with equivalent efficacy for pain in the emergency department Oral ibuprofen provides the same relief as intramuscular ketorolac IM ketorolac is associated with the adverse effect of a painful injection IM ketorolac is slightly faster in onset but not significant Studies have assessed the two medications in head-to-head randomized-controlled trials and found no significant difference in pain scores IM ketorolac takes longer to administer and has a higher cost Ketorolac dosing
2025-02-2403 minEmergency Medical MinuteEpisode 944: Colchicine OverdoseContributor: Aaron Lessen, MD Educational Pearls: Colchicine is most commonly used for the prevention and treatment of gout There is research investigating the anti-inflammatory and cardioprotective effects of colchicine This drug has a narrow therapeutic index: a small margin between effective dose and toxic dose Colchicine overdoses can be unintentional or intentional and are associated with poor outcomes Phase 1: 10 - 24 hours after ingestion Patient looks well but may have mild symptoms mimicking gastroenteritis Phase 2: 24 hours - 7 days after ingestion Multiple organ d...
2025-02-1703 minEmergency Medical MinuteEpisode 943: Portal Vein ThrombosisContributor: Travis Barlock, MD Educational Pearls: What is Portal Vein Thrombosis? The formation of a blood clot within the portal vein, which carries blood from the gastrointestinal tract, pancreas, and spleen to the liver Not only can this cause problems downstream in the liver, but the backup of venous blood can cause ischemia in the bowels How does it present? Similar to acute mesenteric ischemia: Sudden onset of abdominal pain, nausea, vomiting, and fever How is it diagnosed? Abdominal CT or MRI with...
2025-02-1002 minEmergency Medical MinuteEpisode 942: Acute Mountain Sickness and High Altitude Cerebral EdemaContributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Acute mountain sickness (AMS) is the term given to what is otherwise colloquially known as altitude sickness High altitude cerebral edema (HACE) is a severe form of AMS marked by encephalopathic changes Symptoms begin at elevations as low as 6500 feet above sea level for people who ascend rapidly May develop more severe symptoms at higher altitudes The pathophysiology involves cerebral vasodilation Occurs in everyone ascending to high altitudes but is more pronounces in those that develop symptoms ...
2025-02-0303 minEmergency Medical MinuteEpisode 941: Rehydration in Pediatric GastroenteritisContributor: Meghan Hurley, MD Educational Pearls: Gastroenteritis clinical diagnoses: Diarrhea with or without vomiting and fever Vomiting in the absence of diarrhea has a large list of differential diagnoses, so the combination of diarrhea and vomiting in a patient is helpful to indicate the gastroenteritis diagnosis Symptom timeline is usually 1-3 days, but can last up to 14 days – diarrhea persists the longest Treatment for mild to moderate dehydration: oral or IV rehydration Begin orally to avoid unnecessary IV in a pediatric patient Administer OD...
2025-01-2703 minEmergency Medical MinuteEpisode 940: Laceration Repair MethodsContributor: Aaron Lessen, MD Educational Pearls: If a patient sustains a cut, the provider has several options on how to close the wound. If they choose to suture the wound closed, it involves needles both in the form of injecting numbing medication (lidocaine) as well as with the suture itself. Other techniques are "needleless," like closing the wound with adhesive strips (Steri-Strips) or skin adhesive (Dermabond). But which method is best? A recent study looked to compare guardian-perceived cosmetic outcomes of pediatric lacerations repaired with absorbable sutures, Dermabond, and Steri-Strips. It also assessed...
2025-01-2002 minEmergency Medical MinuteEpisode 939: Serotonin SyndromeContributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Serotonin syndrome occurs most commonly due to the combination of monoamine oxidase inhibition with concomitant serotonergic medications like SSRIs Examples of unexpected monoamine oxidase inhibitors Linezolid - a last-line antibiotic reserved for patients with true anaphylaxis to penicillins and cephalosporins Methylene blue - not mentioned in the podcast due to its uncommon usage for methemoglobinemia Other medications that can interact with SSRIs to cause serotonin syndrome Dextromethorphan - primarily an anti-tussive at sigma opioid receptors that also has serotonin...
2025-01-1303 minEmergency Medical MinuteEpisode 938: AHA Policy on Management of Elevated Blood Pressure (BP) in the Acute Care SettingContributor: Aaron Lessen, MD Educational Pearls: Many patients present to the ED with elevated BP Many are referred from outpatient surgery centers or present after an elevated measurement at home Persistent questions on the best way to treat these patients The AHA published a scientific statement on the management of elevated BP in the acute care setting Hypertensive emergencies: SBP/DBP >180/110–120 mm Hg with evidence of new or worsening target-organ damage Includes aortic dissection or subarachnoid hemorrhage Require aggressive treatment Asymptomatic marke...
2025-01-0602 minEmergency Medical MinuteEpisode 936: Etomidate vs. Ketamine for Rapid Sequence IntubationContributor: Ricky Dhaliwal MD Educational Pearls: Etomidate was previously the drug of choice for rapid sequence intubation (RSI) However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity A recent meta-analysis analyzing etomidate as an induction agent showed the following: 11 randomized-controlled trials with 2704 patients Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death The probability of any mortality increase was 98.1% Ketamine is preferable due to...
2024-12-2304 minEmergency Medical MinuteEpisode 935: Pregnancy Extremis - TOLDDContributor: Aaron Lessen MD Educational Pearls: Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD T: Tilt the patient to the left lateral decubitus position This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient's left side
2024-12-1603 minEmergency Medical MinuteEpisode 933: Benign Convulsions with GastroenteritisContributor: Alec Coston MD Educational Pearls: Causes of seizures in a fairly well-appearing child with diarrhea: Electrolyte abnormalities: hypocalcemia, hyponatremia Also hyperkalemia which causes arrhythmias and syncope - can appear like seizures Hypoglycemia If the child has diarrhea and appears very sick, differential diagnosis may include: Hemolytic uremic syndrome (HUS): simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury Typically caused by Shiga-like toxin producing Escherichia coli (also known as EHEC, or enterohemorragic E. coli) One of...
2024-12-0203 minEmergency Medical MinuteEpisode 932: Induction Agent HypotensionContributor: Aaron Lessen MD Educational Pearls: Induction agent selection during rapid sequence intubation involves accounting for hemodynamic stability in the post-intubation setting Many emergency departments use ketamine or etomidate A recent study sought to explore the rates of post-induction hypotension of ketamine compared with propofol Single center retrospective cohort study of patients between 2018-2021 Ketamine and propofol were both significantly associated with post-induction hypotension Ketamine adjusted odds ratio = 4.50 Propofol adjusted odds ratio = 4.88 50% of patients became hypotensive after induction with either propofol...
2024-11-2502 minEmergency Medical MinuteEpisode 931: Naloxone in Cardiac ArrestContributor: Aaron Lessen MD Educational Pearls: Can opioids cause cardiac arrest? Opioids can cause respiratory suppression and the subsequent low oxygen levels can lead to arrhythmias and eventually cardiac arrest. In 2023, 17% of out-of-hospital cardiac arrests (OHCA) were attributable to opioids. Given that this is a rising cause of cardiac arrest, should we just treat all cardiac arrest with naloxone (Narcan)? Naloxone is correlated with an increased chance of return of spontaneous circulation (ROSC) Additionally, a wide variety of individuals can be exposed to opioids and...
2024-11-1803 minEmergency Medical MinuteEpisode 930: Holding CostsContributor: Aaron Lessen MD Educational Pearls: A study evaluated the patient-care impact and financial costs of holding patients in the ED, a nationwide issue Prospective, observational study of acute stroke management Conducted at a large urban, comprehensive stroke center The study evaluated patients in multiple categories: admitted to med/surg admitted to med/surg but held in the ED admitted to the ICU Admitted to ICU but held in the ED Examined the amount of time nurses and providers s...
2024-11-1502 minEmergency Medical MinuteEpisode 928: Neutropenic FeverContributor: Taylor Lynch, MD Educational Pearls: What is neutropenic fever? Specific type of fever that is seen in cancer patients and other patients with impaired immune systems These patients are highly susceptible to infection Typically occurs 7-10 days after the last chemotherapy dose, this is when the immune system is the weakest It is useful to know the specific type of malignancy. For example, heme malignancies (ALL, AML, etc.) have more intense chemo and are at higher risk of neutropenic fever To qualify as a...
2024-10-2805 minEmergency Medical MinuteEpisode 927: Functional Gallbladder SyndromeContributor: Jorge Chalit-Hernandez, OMS3 Typically presents with biliary colic Right upper quadrant abdominal pain lasting more than 30 minutes and subsiding over several hours Often associated with fatty meals but not always Must rule out other causes of pain Peptic ulcer disease - typically presents with epigastric pain Pancreatitis - pain that radiates to the back or family history of pancreatitis Laboratory workup LFTs including ALT, AST, and alkaline phosphatase are within the reference range Lipase and amylase within the reference range
2024-10-2205 minEmergency Medical MinuteEpisode 925: Table Sugar for Tongue EntrapmentContributor: Aaron Lessen, MD Educational Pearls: Pediatric case study where the child's tongue was stuck in the opening of a hard plastic drink lid Entrapment restricts circulation which causes fluid to build and the tongue becomes more edematous with time There is a risk of ischemia with prolonged entrapment Initially tried 2% viscous lidocaine for analgesia and lubricant The ER recognized that this mucosal, edematous tongue could benefit from the trick for ostomies and rectal prolapses → table sugar! Sugar granules absorb water which decreases tissue edema...
2024-10-1401 minEmergency Medical MinuteEpisode 923: Blunt Cerebrovascular InjuryContributor: Travis Barlock MD Educational Pearls: Assessment of head and neck vascular injury due to blunt trauma Symptomatic patients require screening head and neck CT angiography EAST guidelines include the following criteria for a screening CT angiography in blunt head trauma: Unexplained neurological deficits Arterial nosebleed GCS < > Petrous bone fracture Cervical spine fracture Any size fracture through the transverse foramen LeFort fractures type II or type III EAST guidelines include a grading scale for vascular injury:
2024-09-3003 minEmergency Medical MinuteEpisode 922: Chest Tube IrrigationContributor: Aaron Lessen, MD Educational Pearls: Hemothorax: blood in the pleural cavity, most commonly due to chest trauma Treatment: thoracostomy tube for blood drainage helps to avoid clotting, scarring, and infection A recent study looked at patients with hemothorax who either received or did not receive thoracic irrigation with saline Evaluated incidence of secondary intervention, such as video-assisted thoracoscopic surgery (VATS), for persistent hemothorax Patients who received irrigation had a slight decrease in secondary intervention frequency Multi-center study - all patients who had...
2024-09-2302 minEmergency Medical MinuteEpisode 920: Pediatric Growth EstimatesContributor: Sean Fox, MD Educational Pearls: Newborns may lose up to 10% of their birth weight in the first week of life Weight loss is greatest in exclusively breastfed infants Should regain birth weight by age 2 weeks Newborns should gain an average of 30g (1 oz) per day in the first 3 months of life Some will gain more and some will gain less Infants double their birth weight by 6 months of life and triple their weight by 12 months A 1-year-old should weigh on average 10 kg (22...
2024-09-0906 minEmergency Medical MinuteEpisode 919: EKG Criteria for AdenosineContributor: Travis Barlock, MD Educational Pearls: SVT: supraventricular tachycardia Pharmacotherapy for SVT includes drugs that block the AV node, such as adenosine EKG criteria before adenosine administration in SVT Regular rhythm Monomorphic: all QRS complexes are identical If the EKG is polymorphic, with QRS complexes displaying changing morphologies, it is unsafe to administer adenosine Adenosine can worsen polymorphic VTach and lead to VFib References Ganz, Leonard I., and Peter L. Friedman. "Supraventricular Tachycardia." New England Journal of Medicine, vol. 332, no. 3...
2024-09-0401 minEmergency Medical MinuteEpisode 918: Automated Blood Pressure CuffsContributor: Aaron Lessen, MD Educational Pearls: How does an automated blood pressure cuff work? Automated blood pressure cuffs work differently than taking a manual blood pressure. While taking a manual blood pressure, one typically listens for Korotkoff sounds (turbulent flow) while slowly deflating the cuff. An automatic blood pressure cuff only senses the pressure in the cuff itself and specifically pays attention to oscillations in the pressure caused by when the pressure of the cuff is between the systolic (heart squeezing) and diastolic (heart relaxed) pressures. These...
2024-08-2602 minEmergency Medical MinuteEpisode 915: Severe Burn InjuriesContributor: Megan Hurley, MD Educational Pearls: Initial assessment of patients with severe burn injuries begins with ABCs Airway: consider inhalation injury Breathing: circumferential burns of the trunk region can reduce respiratory muscle movement Circulation: circumferential burns compromise circulation Exposure: Important to assess the affected surface area Escharotomy: emergency procedure to release the tourniquet-ing effects of the eschar Differs from a fasciotomy in that it does not breach the deep fascial layer PEEP = positive end-expiratory pressure The positive pressure remaining in...
2024-08-0504 minEmergency Medical MinuteEpisode 913: Vasopressors after ROSCContributor: Travis Barlock MD Educational Pearls: Recent study assessed outcomes after ROSC with epinephrine vs. norepinephrine Observational multicenter study from 2011-2018 285 patients received epineprhine and 481 received norepinephrine Epinephrine was associated with an increase in all-cause mortality (primary outcome) Odds ratio 2.6; 95%CI 1.4-4.7; P = 0.002 Higher cardiovascular mortality (secondary outcome) Higher proportion of unfavorable neurological outcome (secondary outcome) Norepinephrine is the vasopressor of choice in post-cardiac arrest care References Bougouin W, Slimani K, Renaudier M, et al. Epinephrine versus...
2024-07-2301 minEmergency Medical MinuteEpisode 910: Cellulitis Recovery TimelineContributor: Aaron Lessen, MD Educational Pearls: How fast does cellulitis recover? A recent prospective cohort study took a look at this question. The study included 300 adults with cellulitis (excluding those with peri-orbital cellulitis or abscesses) in two emergency departments in Queensland, Australia. They collected data from initial and follow-up surveys at 3, 7, and 14 days, and compared clinician and patient assessments at day 14. Improvement was fastest between day 0 and day 3, with gradual progress thereafter. At day 14, many still had skin redness and swelling, though warmth had often...
2024-07-0201 minEmergency Medical MinuteEpisode 909: Prehospital Blood Pressure Management in Suspected StrokeContributor: Aaron Lessen MD Educational Pearls: A recent study assessed EMS treatment of high blood pressure in the field 2404 patients randomized to prehospital treatment (1205) vs. usual care (1199) Included patients with prehospital BP greater than 150 mm Hg The treatment arm's BP goal was 130-140 mm Hg The primary efficacy outcome was functional status 90 days out Stroke was confirmed by imaging upon hospital arrival On arrival, the mean SBP of the treatment arm was 159 mm Hg compared with 170 mm Hg in the usual care group
2024-06-2402 minEmergency Medical MinuteEpisode 908: Sympathomimetic DrugsContributor: Taylor Lynch MD Educational Pearls: Overview: Sympathomimetic drugs mimic the fight or flight response, affecting monoamines such as dopamine, norepinephrine, and epinephrine Limited therapeutic use, often abused. Types: Amphetamines: Methamphetamine, Adderall, Ritalin, Vyvanse MDMA (Ecstasy) Cocaine (Both hydrochloride salt & free based crack cocaine) Theophylline (Asthma treatment) Ephedrine (For low blood pressure) BZP, Oxymetazoline (Afrin), Pseudoephedrine (Sudafed) MAO Inhibitors (treatment-resistant depression) Mechanisms: Act on adrenergic and dopaminergic receptors. Cocaine blocks dopamine and serotonin reuptake. Methamphetamines increase stimulatory neurotransmitter release MAO Inhibitors prevent neurotransmitter breakdown. Symptoms: Agitation, tachycardia, hypertension, hyperactive bowel sounds, diuresis, hyperthermia. Severe cases: Angina...
2024-06-1707 minEmergency Medical MinuteEpisode 907: Wide-Complex TachycardiaContributor: Travis Barlock MD Educational Pearls: Wide-complex tachycardia is defined as a heart rate > 100 BPM with a QRS width > 120 milliseconds Wide-complex tachycardia of supraventricular origin is known as SVT with aberrancy Aberrancy is due to bundle branch blocks Mostly benign Treated with adenosine or diltiazem Wide-complex tachycardia of ventricular origin is also known as VTach Originates from ventricular myocytes, which are poor inherent pacemakers Dangerous rhythm that can lead to death Treated with amiodarone or lidocaine 80% of...
2024-06-1203 minEmergency Medical MinuteEpisode 906: Case Study of HypernatremiaContributor: Aaron Lessen MD Educational Pearls: The case: A gentleman came in from a nursing home with symptoms concerning for sepsis. He was hypotensive, hypoxic, febrile, and mentally altered. His past medical history included previous strokes which had left him with deficits for which he required a feeding tube. Initial workup included some point of care labs which revealed a sodium of 165 mEq/L (normal range 135-145) Hypernatremia What causes it? Dehydration, from insufficient fluid intake. This might happen in individuals who cannot...
2024-06-0303 minEmergency Medical MinuteEpisode 905: Oseltamivir (Tamiflu) for InfluenzaContributor: Aaron Lessem MD Educational Pearls: Oseltamivir (Tamiflu) is an antiviral medication used commonly to treat influenza Trials show that the medication reduces the duration of illness by less than 1 day (~16 hours in one systematic review) Benefit only occurs if taken within 48 hours of symptom onset Must be taken for 5 days A 2024 meta-analysis reviewed 15 randomized-controlled trials for the risk of hospitalization No reduction in hospitalizations with oseltamivir in patients over the age of 12 No difference in high-risk patients over the age of 65 or t...
2024-05-2702 minEmergency Medical MinuteEpisode 904: Cardiovascular Risks of EpinephrineContributor: Aaron Lessen MD Educational Pearls: Epinephrine is essential in the treatment of anaphylaxis, but is epinephrine dangerous from a cardiovascular perspective? A 2024 study in the Journal of the American College of Emergency Physicians Open sought to answer this question. Methods: Retrospective observational study at a Tennessee quaternary care academic ED that analyzed ED visits from 2017 to 2021 involving anaphylaxis treated with IM epinephrine. The primary outcome was cardiotoxicity Results: Out of 338 patients, 16 (4.7%) experienced cardiotoxicity. Events included ischemic EKG changes (2.4%), elevated troponin (1.8%), atrial arrhythmias (1.5...
2024-05-2002 minEmergency Medical MinuteEpisode 903: Treating Precipitated Opioid WithdrawalContributor: Aaron Lessen MD Educational Pearls: Opioid overdoses that are reversed with naloxone (Narcan), a mu-opioid antagonist, can precipitate acute withdrawal in some patients Treatment of opioid use disorder with buprenorphine can also precipitate withdrawal Opioid withdrawal symptoms include nausea, vomiting, diarrhea, and agitation Buprenorphine works as a partial agonist at mu-opioid receptors, which may alleviate withdrawal symptoms The preferred dose of buprenorphine is 16 mg Treatment of buprenorphine-induced opioid withdrawal is additional buprenorphine Adjunctive treatments may be used for other opioid withdrawal symptoms
2024-05-1302 minEmergency Medical MinuteEpisode 902: Liver Failure and CirrhosisContributor: Travis Barlock MD Educational Pearls: How do you differentiate between compensated and decompensated cirrhosis? Use the acronym VIBE to look for signs of being decompensated. V-Volume Cirrhosis can cause volume overload through a variety of mechanisms such as by increasing pressure in the portal vein system and the decreased production of albumin. Look for pulmonary edema (dyspnea, orthopnea, wheezing/crackles, coughing up frothy pink sputum, etc.) or a tense abdomen. I-Infection The ascitic fluid can become infected with bacteria, a complication called...
2024-05-0603 minEmergency Medical MinuteEpisode 901: Underdosing in Status EpilepticusContributor: Aaron Lessen MD Educational Pearls: Lorazepam (Ativan) is dosed at 0.1 mg/kg up to a maximum of 4 mg in status epilepticus Some ED protocols only give 2 mg initially The maximum recommended dose of levetiracetam (Keppra) is 60 mg/kg or 4.5 g In one retrospective study, only 50% of patients received the correct dose of lorazepam For levetiracetam, it was only 35% of patients Underdosing leads to complications Higher rates of intubations More likely to progress to refractory status epilepticus References
2024-04-2902 minEmergency Medical MinuteEpisode 900: Ketamine DosingContributor: Travis Barlock MD Educational Pearls: Ketamine is an NMDA receptor antagonist with a wide variety of uses in the emergency department. To dose ketamine remember the numbers 0.3, 1, and 3. Pain dose For acute pain relief administer 0.3 mg/kg of ketamine IV over 10-20 minutes (max of 30 mg). Note: There is evidence that a lower dose of 0.1-0.15 mg/kg can be just as effective. Dissociative dose To use ketamine as an induction agent for intubation or for procedural sedation administer 1 mg/kg IV over 1-2...
2024-04-2202 minEmergency Medical MinuteEpisode 899: Thrombolytic ContraindicationsContributor: Travis Barlock MD Educational Pearls: Thrombolytic therapy (tPA or TNK) is often used in the ED for strokes Use of anticoagulants with INR > 1.7 or PT >15 Warfarin will reliably increase the INR Current use of Direct thrombin inhibitor or Factor Xa inhibitor aPTT/PT/INR are insufficient to assess the degree of anticoagulant effect of Factor Xa inhibitors like apixaban (Eliquis) and rivaroxaban (Xarelto) Intracranial or intraspinal surgery in the last 3 months Intracranial neoplasms or arteriovenous malformations also increase the risk of bleeding...
2024-04-1503 minEmergency Medical MinuteEpisode 898: Takotsubo CardiomyopathyContributor: Ricky Dhaliwal, MD Educational Pearls: Takotsubo cardiomyopathy, also known as "broken heart syndrome," is a temporary heart condition that can mimic the symptoms of a heart attack, including troponin elevations and mimic STEMI on ECG. The exact cause is not fully understood, but it is often triggered by severe emotional or physical stress. The stress can lead to a surge of catecholamines which affects the heart (multivessel spasm/paralysed myocardium). The name "Takotsubo" comes from the Japanese term for a type of octopus trap, as the left ventricle takes on...
2024-04-1003 minEmergency Medical MinuteEpisode 897: Adrenal CrisisContributor: Ricky Dhaliwal MD Educational Pearls: Primary adrenal insufficiency (most common risk factor for adrenal crises) An autoimmune condition commonly known as Addison's Disease Defects in the cells of the adrenal glomerulosa and fasciculata result in deficient glucocorticoids and mineralocorticoids Mineralocorticoid deficiency leads to hyponatremia and hypovolemia Lack of aldosterone downregulates Endothelial Sodium Channels (ENaCs) at the renal tubules Water follows sodium and generates a hypovolemic state Glucocorticoid deficiency contributes further to hypotension and hyponatremia Decreased vascular responsiveness to angiotensin II
2024-04-0104 minEmergency Medical MinuteEpisode 895: Indications for Exogenous AlbuminContributor: Travis Barlock MD Educational Pearls: There are three indications for IV albumin in the ED Spontaneous bacterial peritonitis (SBP) Patients with SBP develop renal failure from volume depletion Albumin repletes volume stores and reduces renal impairment Albumin binds inflammatory cytokines and expands plasma volume Reduced all-cause mortality if IV albumin is given with antibiotics Hepatorenal syndrome Cirrhosis of the liver causes the release of endogenous vasodilators The renin-angiotensin-aldosterone system (RAAS) fails systemically but maintains vasoconstriction at the kidneys...
2024-03-1802 minEmergency Medical MinuteEpisode 893: Home Treatments for Button Battery IngestionContributor: Aaron Lessen MD Educational Pearls: Button batteries cause alkaline corrosion and erosion of the esophagus when swallowed Children swallow button batteries, which create a medical emergency as they can perforate the esophagus A recent study compared various home remedies as first-aid therapy for button battery ingestion Honey, jam, normal saline, Coca-Cola, orange juice, milk, and yogurt The study used a porcine esophageal model to assess resistance to alkalinization with the different home remedies Honey and jam demonstrated a significantly lower esophageal tissue pH compared...
2024-03-0402 min
Emergency Medical MinutePharmacy Phriday #11: Riddles, Medical Jargon, NNT, and Time TravelContributors: Kali Olson PharmD, Travis Barlock MD, Jeffrey Olson MS2 Summary: In this episode of Pharmacy Phriday, Dr. Kali Olson joins Dr. Travis Barlock and Jeffrey Olson in studio to discuss a variety of interesting topics in the form of a segment show. Dr. Kali Olson earned her Doctorate of Pharmacy from the University of Colorado, Skaggs School of Pharmacy and completed a PGY1 residency at Detroit Receiving Hospital and a PGY2 residency in Emergency Medicine at Denver Health. She now works as an Emergency Medicine Pharmacist at Denver Health. In segment one o...
2024-02-2343 minEmergency Medical MinutePodcast 890: Outdoor Cold Air for CroupContributor: Jared Scott MD Educational Pearls: Croup is a respiratory condition typically caused by a viral infection (e.g., parainfluenza). The disease is characterized by inflammation of the larynx and trachea, which often leads to a distinctive barking cough. A common treatment for croup is the powerful steroid dexamethasone, but it can take up to 30 minutes to start working. A folk remedy for croup is to take the afflicted child outside in the cold to help them breathe better, but does it really work? A 2023 study in Switzerland, published...
2024-02-1404 minEmergency Medical MinutePodcast 889: Blood Pressure Cuff SizeContributor: Aaron Lessen MD Educational Pearls: Does the size of a blood pressure (BP) cuff matter? A recent randomized crossover trial revealed that, indeed, cuff size can affect blood pressure readings Design 195 adults with varying mid-upper arm circumferences were randomized to the order of BP cuff application: Appropriate Too small Too large Individuals had their mid-upper arm circumference measured to determine the appropriate cuff size Participants underwent 4 sets of triplicate blood pressure measurements, the last of which was always...
2024-02-0501 minEmergency Medical MinutePodcast 888: Low GCS and IntubationContributor: Aaron Lessen MD Educational Pearls: Is the adage, "GCS of 8, you've got to intubate" accurate? A recent study published in the November 2023 issue of JAMA attempted to answer this question. Design Multicenter, randomized trial, in France from 2021 to 2023. 225 patients experiencing comatose in the setting of acute poisoning were randomly assigned to either a conservative airway strategy of withholding intubation or "routine practice" of much more frequent intubation. The primary outcome was a composite endpoint including in-hospital death, length of intensive care unit stay, and length of...
2024-01-2902 minEmergency Medical MinutePodcast 887: Family Presence in Cardiac ResuscitationContributor: Aaron Lessen MD Educational Pearls: A 2013 study randomized families of those in cardiac arrest into two groups: Actively offered patients' families the opportunity to observe CPR Follow standard practice regarding family presence (control group) Of the 266 relatives that received offers to observe CPR, 211 (79%) accepted vs. 43% in the control group observed CPR The study assessed a primary end-point of PTSD-related symptoms 90 days after the event Secondary end-points included depression, anxiety, medicolegal claims, medical efforts at resuscitation, and the well-being of the healthcare team ...
2024-01-2202 minEmergency Medical MinutePodcast 883: Migraine Treatment in Cardiovascular DiseaseContributor: Jorge Chalit, OMS II Educational Pearls: Migraine pathophysiology Primarily mediated through the trigeminovascular system Serotonin, dopamine, and calcitonin gene-related peptide (CGRP) Trigeminovascular system is linked to the trigeminal nucleus caudalis, which relays pain to the hypothalamus and cerebral cortex One effective treatment for acute migraines is -triptan medications 5-HT1D/1B agonists such as sumatriptan Often combined with NSAIDs and dopamine antagonists (as antiemetics) in migraine cocktails Diphenhydramine (Benadryl) was shown to be ineffective in a randomized controlled trial comparing...
2023-12-2503 minEmergency Medical MinutePodcast 882: Thrombolytics for Minor StrokesContributor: Aaron Lessen MD Educational Pearls: How is the severity of a stroke assessed? Strokes are assessed by the NIH Stroke Scale (NIHSS), this scale has different tasks, such as asking the person to repeat words, move their arms, or follow simple instructions. The maximum score is 42 but any score over 21 is considered severe. What would qualify as a minor storke? NIH
2023-12-2002 minEmergency Medical MinutePodcast 881: Pediatric ReadmissionsContributor: Nick Tsipis MD Educational Pearls: The review article assessed 16.3 million patients across six states to identify those at high-risk for critical revisit Criteria for critical revisit was ICU admission or death within three days of discharge from the ED Critical revisits are extremely rare 0.1% of patients have a critical revisit after discharge 0.00001% die after revisit Of the patients that do experience critical revisits, the two major risk factors are Asthma - relative risk 2.24 Chronic medical conditions - incidence rate ratio 11.03
2023-12-1203 minEmergency Medical MinutePodcast 879: A Case of Pediatric Anaphylactic ShockContributor: Dr. Taylor Lynch Educational Pearls: Time of arrival until intubation was 26 minutes but nobody tried anterior neck access like a cricothyrotomy until his dad arrived Traditional ACLS protocol is not enough for anaphylactic respiratory arrest Circulating O2 from compressions alone is not enough to sustain the brain Patients need a definitive airway and endotracheal tube is the best method BVM ventilation is not enough to get patients the oxygen they need Time to anoxic brain injury during a respiratory arrest is 4 minutes ...
2023-11-2705 minEmergency Medical MinutePodcast 878: Opioids for Low Back and Neck PainContributor: Jared Scott MD Educational Pearls: Should we use opioids to treat low back and neck pain? The OPAL Trial, published in The Lancet, in June 2023, attempted to answer this very question. Objective: Investigate the efficacy and safety of a short course of opioid analgesic (oxycodone-naloxone) for acute low back pain and neck pain. Trial Design: Triple-blinded, placebo-controlled randomized trial, conducted in Emergency and Primary Care in Sydney, Australia, involving adults with 12 weeks or less of low back or neck pain. Participants: 347 recruited adults (174 in the opioid group, 173 in...
2023-11-2003 minEmergency Medical MinutePodcast 877: Viral Respiratory Infections in ChildrenContributor: Jared Scott MD Educational Pearls A recently published study assessed the burden of respiratory viruses in a longitudinal cohort of children from 0 to 2 years of age The children in the study received nasal swab PCR testing weekly to determine infectivity They were also monitored for symptoms via weekly text surveys The study differentiated between infection and illness by defining an acute respiratory illness (ARI) as fever ≥38°C or cough. The median infectivity rate was 9.4 viral infections per child per year The median illness rate was...
2023-11-1303 minEmergency Medical MinutePodcast 875: A Pediatric Case of MyopericarditisContributor: Meghan Hurley MD Educational Pearls: Pericarditis is inflammation of the pericardial sac, which can arise from infectious or non-infectious etiologies Myocarditis is inflammation of the myocardium, which may accompany pericarditis Pericarditis clinical findings include: Diffuse concave ST elevation, classic for acute pericarditis with myocardial involvement. More common in younger male patients Elevated high-sensitivity troponin - higher levels may occur in young healthy patients Ultrasound may show pericardial effusions POCUS may be helpful in assessing left ventricular ejection fraction (LVEF) via E-point septal...
2023-10-3006 minEmergency Medical MinuteEpisode 874: BradyarrhythmiasContributor: Dylan Luyten MD Educational Pearls: What is a Bradyarrhythmia? Also known as a bradyarrhythmia, it is an irregular heart rate that is also slow (below 60 beats per minute). What can cause it? Complete heart block AKA third-degree AV block; identified on ECG by a wide QRS, and complete dissociation between the atrial and ventricular rhythms with the ventricular being much slower. Treat with a pacemaker. Medication overdose, especially beta blockers. Many other drugs can slow the heart as well including: opioids, clonidine, digitalis, amiodarone, diltiazem, and...
2023-10-2302 minEmergency Medical MinutePodcast 873: Intravesical Tranexamic Acid for Gross HematuriaContributor: Aaron Lessen MD Educational Pearls: Tranexamic acid (TXA) is a common medication to achieve hemostasis in a variety of conditions Patients visiting the ED for gross hematuria (between March 2022 and September 2022) were treated with intravesical TXA 1 g tranexamic acid in 100 mL NS via Foley catheter Clamped Foley for 15 minutes Subsequent continuous bladder irrigation, as is standard in most EDs Compared with a cohort of patients visiting the ED for a similar concern between March 2021 and September 2021, the TXA patients had: A shorter...
2023-10-1602 minEmergency Medical MinutePodcast 871: Increased Intracranial Pressure and the Cushing ReflexContributor: Travis Barlock MD Education Pearls: The Cushing Reflex is a physiologic response to elevated intracranial pressure (ICP) Cushing's Triad: widened pulse pressure (systolic hypertension), bradycardia, and irregular respirations Increased ICP results from systolic hypertension, which causes a parasympathetic reflex to drop heart rate, leading to Cushing's Triad. The Cushing Reflex is a sign of herniation Treatment includes: Hypertonic saline is comparable to mannitol and preferable in patients with hypovolemia or hyponatremia Give 250-500mL of 3%NaCl 20% Mannitol - given at a...
2023-10-0203 minEmergency Medical MinuteEpisode 868: Airway Management in ObesityContributor: Aaron Lessen MD Educational Pearls: Why is airway management more difficult in obesity? Larger body habitus causes the chest to be above the head when the patient is lying supine, creating difficult angles for intubation. Reduced Functional Residual Capacity (FRC) causes these patients to deoxygenate much more quickly, reducing the amount of time during which the intubation can take place. What special considerations need to be made? Positioning. The auditory canal and sternal notch should be aligned in a horizontal plane. Do this by stacking blankets...
2023-09-1103 minEmergency Medical MinuteEpisode 867: Occult Scaphoid FracturesContributor: Nick Tsipis MD Educational Pearls: The scaphoid bone is the most proximal carpal bone just distal to the radius Fractures of the scaphoid bone are sometimes missed by plain X-rays A 2020 review found a 21.8% incidence of missed scaphoid fractures later diagnosed by advanced imaging modalities Only MRI has a sensitivity above 90% for diagnosing scaphoid fractures Sensitivity of plain-film radiography is low unless it is a displaced fracture Physical examination techniques fail to definitively rule out scaphoid fractures A 2023 systematic review assessed the sensitivity...
2023-09-0404 minEmergency Medical MinutePodcast 866: Carbamazepine (Tegretol) OverdoseContributor: Aaron Lessen MD Educational Pearls: What is Carbamazepine (Tegretol)? Carbamazepine is an anti-epileptic drug with mood-stabilizing properties that is used to treat bipolar disorder, epilepsy, and neuropathic pain. It functions primarily by blocking sodium channels which can prevent repetitive action potential firing. What are the symptoms of an overdose? Common initial signs include diminished conscious state, nystagmus, ataxia, hyperreflexia, CNS depression, dystonia, and tachycardia Severe toxicity can cause seizures, respiratory depression, decreased myocardial contractility, pulmonary edema, hypotension, and dysrhythmias. How is an...
2023-08-2802 minEmergency Medical MinuteLaboring Under Pressure- Episode 1. ACLS in Pregnancy with Dr. Jason PapazianContributor: Jason Papazian MD, Travis Barlock MD, Jeffrey Olson Summary: In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss several clips from Dr. Jason Papazian's talk at the event "Laboring Under Pressure, Managing Obstetric Emergencies in a Global Setting" from May 2023. This event was hosted at the University of Denver and was organized with the help of Joe Parker as a fundraiser for the organization Health Outreach Latin America (HOLA). Dr. Jason Papazian practices Obstetric Anesthesiology for the Maternal Fetal Care Unit at Children's Hospital C...
2023-08-2432 minEmergency Medical MinutePodcast 865: Nausea Treatments - Droperidol vs Ondansetron RCTContributor: Aaron Lessen MD Educational Pearls: A recent randomized controlled trial compared ondansetron 8 mg IV with droperidol 2.5 mg IV for the treatment of nausea & vomiting in the emergency department. Overall, droperidol and ondansetron had similar primary outcomes in acute nausea control Symptom improvement in 93% of patients receiving droperidol vs. 87% receiving ondansetron (P = 0.362) Secondary measures were, however, statistically significantly different between groups Patients needed fewer rescue/additional antiemetics in the droperidol group (16%) compared with the ondansetron group (37%); p = 0.016 Similarly, more patients in the droperidol group reported th...
2023-08-2102 minEmergency Medical MinutePodcast 864: Arterial Blood Gas (ABG) vs Venous Blood Gas (VBG)Contributor: Aaron Lessen MD Educational Pearls: What is measured in an ABG/VBG? Blood values for oxygen tension (pO2), carbon dioxide tension (pCO2), acidity (pH), oxyhemoglobin saturation, and bicarbonate (HCO3) in either arterial or venous blood Other tests can measure methemoglobin, carboxyhemoglobin, hemoglobin levels, base excess, and lactate What are they used for? Identification of ventilation/acid-base disturbances. For example: if a patient is in septic shock, oxyhemoglobin saturation can be used to guide resuscitation efforts (early goal- directed therapy) What's the difference between an...
2023-08-1402 minEmergency Medical MinutePodcast 863: Treatments for Alcohol Use DisorderContributor: Aaron Lessen MD Educational Pearls: Patients with alcohol use disorder are frequently discharged from the ED without further resources Pharmacological treatments to reduce cravings in AUD exist Naltrexone Effective at reducing alcohol cravings and heavy drinking Gabapentin Reduces the percentage of heavy drinking days in AUD Patients being discharged from the ED should be asked if they feel their alcohol use is a problem, which can further direct appropriate pharmacological interventions References 1. Kranzler M.D. HR, Feinn Ph.D...
2023-08-0702 minEmergency Medical MinutePodcast 862: How to Apply a Painful StimulusContributor: Travis Barlock MD Educational Pearls: When might you need to apply a painful stimulus in a medical setting? The main reason is to assess the patient's level of consciousness, such as when they are waking up from anesthesia or have potentially suffered a brain injury. It can be part of the Glasgow Coma Scale (GCS) if patients are not responding to auditory stimuli. Possible levels of consciousness include Alert, Lethargic, Obtunded, and Comatose (ALOC) What are the approved ways to apply a painful stimulus to assess...
2023-07-3102 minEmergency Medical MinutePodcast 861: Alcohol Withdrawal and Delirium TremensContributor: Travis Barlock MD Educational Pearls: Alcohol binds the GABA receptor, which produces an inhibitory response, hence the "depressive" effects of ethanol beverages. Over time, alcohol downregulates the GABA receptors, leading to unopposed glutamate activity. Given that glutamate is excitatory, this can lead to seizures. Alcohol also suppresses REM sleep; in patients with chronically suppressed REM sleep, the brain starves for dream sleep and it spills over into the wakeful state, inducing a dream-like state when someone is awake. The awake dream-like state of delirium tremens (DT) differs from...
2023-07-2404 min
Emergency Medical MinuteUkraine Brewtalk Featuring Dr. Dave YoungContributors: David Young MD, John Hesling MD, Travis Barlock MD, Jeffrey Olson Summary: In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss several clips from the event "Ukraine Brewtalk" from October 2022. This event was hosted by the University of Colorado's Center for COMBAT Research and Emergency Medical Minute assisted in the audio recording of the speakers. The first clip is of a brief talk by Dr. John Hesling who was presenting some of his research about Pediatric Supermassive Transfusions. The second and third clips are...
2023-07-2138 minEmergency Medical MinutePodcast 860: ThyrotoxicosisContributor: Travis Barlock MD Educational Pearls: Clinical picture: A patient comes in with altered mental status, tachycardia, fever, elevated T4, and low TSH. What's the diagnosis?... Thyrotoxicosis secondary to Graves' Disease. How do you treat thyrotoxicosis? First, give a beta-blocker such as propranolol. This suppresses the elevated adrenergic activity. Second, give a thionamide such as propylthiouracil (PTU) or methimazole. This decreases the synthesis of new thyroid hormone. PTU is preferred because it also blocks the conversion of T4 to T3. Third, give an iodine solution such as...
2023-07-2002 minEmergency Medical MinutePodcast 859: Teamwork Really Makes the Dream WorkContributor: Aaron Lessen MD Educational Pearls: 33 Medical residents and 91 nurses at Massachusetts General Hospital were randomized into two groups: Intervention group: 15 PGY-1 residents assigned to the same medical service floor for a 16-week period (12 weeks after adjustment for COVID-19 restrictions) alongside 43 nurses. Control group: 18 PGY-1 residents assigned to the usual 4-week block rotations across 6 medical floors. At 6 months, there were no differences in teamwork performance metrics including advanced medical simulations and nurse presence at rounds. The 12-month assessment demonstrated improvement in performance metrics. Increased time t...
2023-07-1002 minEmergency Medical MinutePodcast 858: Whole Blood Pregnancy TestContributor: Meghan Hurley MD Educational Pearls: What do you do if you need a stat pregnancy test on an incapacitated patient? You can send a serum quantitative human chorionic gonadotropin (beta-HCG), but that might take a while for the lab to process. Another option is to place a drop of whole blood on a urine pregnancy immunoassay. These tests are already verified for urine and serum. 2012 study showed that whole blood was 95.8% sensitive for pregnancy compared to 95.3% for urine. Takes a little bit longer (10 minutes...
2023-07-0304 minEmergency Medical MinutePodcast 857: Alice in Wonderland JeopardyContributor: Chris Holmes MD Educational Pearls: "It's a poor sort of memory that only works backwards" - Transient Global Amnesia A syndrome with sudden retrograde memory loss in which patients cannot retain new information Characterized by perseveration in frequent intervals Typically improves within hours MRI is normal initially Alice In Wonderland Syndrome A disorder in which patients experience distortions in their visual perceptions Most often characterized by micropsia and/or macropsia Other symptoms may include illusory movement or wavy...
2023-06-2603 minEmergency Medical MinutePodcast 855: QT IntervalsContributor: Travis Barlock MD Educational Pearls The QT interval represents phases 2 and 3 of ventricular plateau and repolarization, respectively. As the QT interval lengthens, more sodium and calcium channels are available and susceptible to action potentials. Prolonged QT interval is more concerning in the setting of bradycardia. This scenario increases the likelihood of R on T phenomenon. R on T phenomenon occurs due to an early afterdepolarization event in which a premature ventricular contraction (PVC) occurs during the repolarization period (superimposed on the T wave), leading to an aberr...
2023-06-1204 min
Emergency Medical MinuteMental Health Monthly #16: Psychosis in the ED Part IIContributors: Andrew White MD & Travis Barlock MD In this follow-up episode Dr. Andrew White, a practicing psychiatrist with an addiction medicine fellowship, and Dr. Travis Barlock, an emergency physician at Swedish Medical Center, discuss mental health holds, psychiatric placement, pharmacologic vs. non-pharmacologic treatments, and outpatient care of psychotic patients. If you missed it, be sure to listen to part I for details on the management of psychotic patients in the ED. Educational Pearls: Mental health holds should be approached on a case-by-case basis; this includes assessing safety risks immediately, over a 24-hour period, and...
2023-06-0724 minEmergency Medical MinuteEpisode 854: Tranq (xylazine) with HeroinContributor: Aaron Lessen, MD Educational Pearls: What is Tranq? Tranq is the street name for xylazine, a sedative drug typically used in veterinary medicine. Xylazine has recently emerged as a recreational drug, often mixed with heroin or fentanyl. The mechanism of action of xylazine is similar to dexmedetomidine (Precedex), an alpha-2 adrenergic receptor agonist. At toxic levels, either by itself or when combined with opioids, can cause apnea, bradycardia, coma, and hypotension. How is it different from other adulterants, such as fentanyl? Because I...
2023-06-0502 minEmergency Medical MinutePodcast 853: Critical Care Medications - VasopressorsContributor: Travis Barlock MD Educational Pearls: Three categories of pressors: inopressors, pure vasoconstrictors, and inodilators Inopressors: Epinephrine - nonselective beta- and alpha-adrenergic agonism, leading to increased cardiac contractility, chronotropy (increased heart rate), and peripheral vasoconstriction. Dose 0.1mcg/kg/min. Levophed (norepinephrine) - more vasoconstriction peripherally than inotropy; useful in most cases of shock. Dose 0.1mcg/kg/min. Peripheral vasoconstrictors: Phenylephrine - pure alpha agonist; useful in atrial fibrillation because it avoids cardiac beta receptor activation and also in post-intubation hypotension to counteract the RSI medications. S...
2023-05-2905 minEmergency Medical MinutePodcast 852: Angioedema After ThrombolysisContributor: Aaron Lessen, MD Educational Pearls: What is thrombolysis? Thrombolysis is performed by administration of a medication that promotes the body's natural ability to break up clots. These medications include Alteplase (tPA) and Tenecteplase (TNK). The main side effect of using such an agent is bleeding which typically occurs at puncture sites but can also occur internally. However, an unusual side effect of thrombolytic agents, which occurs in about 1-5% of cases, is angioedema. What is angioedema? Angioedema is a medical condition that causes swelling beneath the...
2023-05-2202 minEmergency Medical MinutePodcast 851: High-Dose Nitroglycerin in SCAPEContributor: Aaron Lessen MD Educational Pearls: SCAPE (Sympathetic Crashing Acute Pulmonary Edema), formerly known as flash pulmonary edema, is a life-threatening condition due to a sudden sympathetic surge that leads to hypertensive heart failure, pulmonary edema, hypoxia, and respiratory distress. The initial treatment for SCAPE stabilization is BiPAP to assist with ventilation. Pharmacological treatment for SCAPE is best achieved with high-dose nitroglycerin (HDN), which induces venodilation and redistributes pulmonary edema. Dosing should be high; boluses of HDN are given at doses of 1-2 mg every 3-5 minutes vs. infusions at 200-400 mcg/min then titrating down. H...
2023-05-1503 minEmergency Medical MinutePodcast 850: Cardiac Arrest - Entertainment vs. RealityContributor: Travis Barlock, MD Educational Pearls: Sudden Cardiac Arrest (SCA) is defined as when the heart suddenly stops beating. Immediate treatment for SCA includes Cardiopulmonary Resuscitation (CPR) and defibrillation. This event is commonly depicted in medical dramas as an intense moment but often with the patient surviving and making a full recovery (67-75%). This depiction has likely led the general population astray when it comes to the true survivability of SCA. When surveyed, the general population tends to believe that in excess of 50% of patients requiring CPR survive and return to daily life with no...
2023-05-0802 min
Emergency Medical MinuteMental Health Monthly #15: Psychosis in the ED: Part IContributors: Andrew White MD & Travis Barlock MD In this episode of Mental Health Monthly, Dr. Andrew White, a practicing psychiatrist with an addiction medicine fellowship, and Dr. Travis Barlock, an emergency physician at Swedish Medical Center, discuss the various presentations and etiologies of acute psychosis. They explore the medical presentations compared with primary psychiatric manifestations and how to narrow the differential. Furthermore, Dr. Barlock discusses the management of psychotic patients from the ED perspective while Dr. White provides invaluable insight into their respective psychiatric care. Educational Pearls: Auditory hallucinations are more consistent with primary...
2023-05-0331 minEmergency Medical MinutePodcast 849: Large Vessel OcclusionsContributor: Travis Barlock MD Educational Pearls: Large Vessel Occlusion (LVO) is a condition where a clot blocks one of the major blood vessels in the brain, leading to a stroke. What are the vessels that can experience an LVO? Middle Cerebral artery (MCA) Internal Carotid Artery (ICA) Anterior Cerebral Artery (ACA) Posterior Cerebral Arteries (PCA) Basilar Artery (BA) Vertebral Arteries (VA) What are the locations at which a mechanical thrombectomy can be performed as a treatment for an LVO?
2023-05-0103 min
Emergency Medical MinutePodcast 848: Non-Traditional RSIContributor: Meghan Hurley, MD Educational Pearls: Two main reasons to choose non-traditional RSI Anatomically challenging airway Physiologically difficult patients: hypoxia, metabolic acidosis, hemodynamic instability Ketamine may help patients remain hemodynamically stable In critical patients, it is important to consider non-traditional RSI medications to improve outcomes References 1. Lyon RM, Perkins ZB, Chatterjee D, Lockey DJ, Russell MQ. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care. 2015;19(1). doi:10.1186/s13054-015-0872-2 2. Merelman AH, Perlmutter M...
2023-04-2405 min
Human RecursosThe Evolution of Human ResourcesIn this episode of Human Recursos host, Jacob Monty, is joined by guest host and HR expert, Jorge Chalit, to discuss the evolution of Human Resources. Jorge Chalit who after 30 years of HR experience, has dubbed himself “The HR Anarchist”, adds valuable insight to the spirited conversation. Listen as Jacob and Jorge discuss recruiting tips, the growth of unions, the #MeToo movement, the balance a HR professional must achieve between management's goals and employee advocacy, and the future of HR.
2022-07-1958 min
Emergency Medical MinuteMental Health Monthly #13: Substance-Induced Psychosis (Part I)Substance-Induced Psychosis (Part I) In this first episode of a two-part mini-series, we feature Dr. Nadia Haddad, a Colorado psychiatrist, and Dr. Ricky Dhaliwal, an emergency medicine physician, as they discuss the different substances that cause psychosis and their unique presentations in the ED and in the psychiatric world. First, Dr. Haddad establishes a medical definition of psychosis. Then, Dr. Haddad and Dr. Dhaliwal partake in a fruitful discussion, each providing their unique perspective on the drugs that affect our patient populations today. Key Points: Psychosis is a cognitive processing disorder, which lea...
2022-06-0816 min
Emergency Medical MinuteMental Health Monthly #9: Suicide Assessment in the ED: Using the ICAR2E ToolDr. Kim Nordstrom discusses a valuable bedside tool for evidence-based assessment in patients that visit the ED and are at risk for suicidality. Dr. Nordstrom is a practicing emergency psychiatrist and associate professor with the University of Colorado. As a developer and user of the tool, Dr. Nordstrom gives us invaluable insight into a new avenue for psychiatric care in emergency medicine. Educational Pearls: An app-based tool made in conjunction with ACEP Identifying suicidal risk for each patient, including assessment of clues like bodily injuries Communicating with patients to create a safe sp...
2022-01-2608 min