Shows
Emergency 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 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 min
Emergency Medical MinutePodcast 812: PO MedicationsContributor: Nick Tsipis, MD Educational Pearls: PO medications are less frequently used in the ED due to their longer onset of action The position the patient is in when given PO medications may affect how quickly the medication is absorbed The quicker the medication passes through the stomach into the small intestine, the quicker it can be absorbed and metabolized Recent study used in silico gastric biomechanics model to compare the length of time it took PO medications to pass through the stomach based on the patient's positioning Compared the medication transit time in a stomach model p...
2022-09-1203 min
Emergency Medical MinutePodcast 759: Hyperkalemia and Myth of KayexalateContributor: Nick Tsipis, MD Educational Pearls: Acute hyperkalemia is characterized as serum K of 5.4 or higher in non-hemolyzed samples Hyperkalemia is commonly associated with end stage renal disease, acute kidney injury or acute renal failure Cardiac dysrhythmias are the primary concern with hyperkalemia, common EKG changes (and approximate serum levels) can include: Peaked T waves that start to show at serum K of 6 Second sign is lengthening of PR and QRS intervals due to extended repolarization Severe hyperkalemia manifests as a sine wave around serum of 8-9 Three approaches to treat hyperkalemia: Stabilize cardiac membrane with c...
2022-02-2805 min
Emergency Medical MinutePodcast 758: Vaccine Safety During PregnancyContributor: Nick Tsipis, MD Educational Pearls: Observational study in Israel evaluated cohort of vaccinated pregnant women receiving the initial Pfizer-BioNTech COVID-19 mRNA vaccine Looked at 24,288 newborns with about 16,697 exposed to maternal vaccination in utero Longitudinal follow up showed no significant difference in preterm births, neonatal hospitalizations, post-natal hospitalizations, congenital abnormalities, or mortality While this is not a randomized-controlled trial, this observational trial has a very large population that was studied supporting the safety profile of birth outcomes relating to receiving COVID mRNA vaccines during pregnancy References Goldshtein I, Steinberg DM, Kuint J, et a...
2022-02-2203 minEmergency Medical MinutePodcast 749: PCC for Me?Contributor: Nick Tsipis, MD Educational Pearls: Prothrombin complex concentrate (Kcentra) and Vitamin K are used to reverse life-threatening bleeds in patients on warfarin (Coumadin) Factors II, VII, IX, and X are included in four-factor PCC PCC/Kcentra dosing is 500-2000 units based on INR and patient weight PROPER3 RCT was a non-inferiority trial done to evaluate standardized dosing of PCC/Kcentra versus variable dosing based on INR and weight Looked at end-points to assess hemostasis, but ultimately this trial did not show non-inferiority of standardized dosing compared to variable dosing References Abdoellakhan RA, Khorsand N, T...
2022-01-2404 minEmergency Medical MinutePodcast 728: Angiography for Out-of-Hospital Cardiac Arrest without ST ElevationContributor: Nick Tsipis, MD Educational Pearls: Meaningful survival under 10% for out of hospital cardiac arrest The most common cause of out-of-hospital cardiac arrest is due to cardiac ischemia Study looked at whether taking patients without ST elevation who had an out-of-hospital cardiac arrest with return of spontaneous circulation (ROSC) should receive angiography upon arrival to the hospital Took 530 patients and randomized to early vs. delayed angiography after resuscitation from out-of-hospital arrest Found no benefit to early angiography using 30-day all-cause risk of death as the primary endpoint References Desch S, Freund A, Akin...
2021-11-0905 min
Emergency Medical MinutePodcast 716: Resuscitation FluidsContributor: Nick Tsipis, MD Educational Pearls: Fluid choice may have an impact on outcomes in resuscitation, and a meta-analysis has relevant insight into their use in sepsis and trauma patients Large volume normal saline fluid resuscitation in sepsis is associated with acute kidney injury and metabolic acidosis compared to Lactated Ringers Choice of fluid did not have significant differences in trauma patients for initial resuscitation References Tseng CH, Chen TT, Wu MY, Chan MC, Shih MC, Tu YK. Resuscitation fluid types in sepsis, surgical, and trauma patients: a systematic review and sequential network...
2021-09-2904 min
Emergency Medical MinutePodcast 710: Droperidol vs. ZyprexaContributor: Nick Tsipis, MD Educational Pearls: Prospective trial studied 5 mg IM droperidol to 10 mg IM olanzapine (Zyprexa) in the reducing levels of agitation Time to adequate sedation was about 16 minutes for both agents Droperidol was slightly less sedating than olanzapine and length of stay for olanzapine was longer Olanzapine had a higher rate of requiring another agent for adequate sedation Droperidol had a higher rate of adverse events (mainly extrapyramidal symptoms) than olanzapine Remember to put the safety of the staff and patient at the forefront of sedation practices and be cognizant of the psychological effect...
2021-08-3105 min
Emergency Medical MinutePodcast 693: Humerus FracturesContributor: Nick Tsipis, MD Educational Pearls: Humerus fractures can be characterized as proximal, midshaft, and distal fractures Proximal humerus fracture is the second-most common fracture in elderly patients Primary complication is with the axillary nerve and axillary artery Vast majority are managed nonoperatively with a sling, reduction usually not indicated Women comprise 70% of proximal humerus fractures, often secondary to fall with osteoporosis Midshaft humerus fractures are more often managed operatively, but can be managed nonoperatively Primary complication is with radial nerve, look for wrist drop! May require reduction and splinting Distal humerus fractures can include supracondylar fr...
2021-07-1407 min
Emergency Medical MinutePodcast 684: AcidosisContributor: Nick Tsipis, MD Educational Pearls: pH 7.45=alkalemia If pH low and pCO2 high, indicates a respiratory acidosis If pH low and pCO2 low, indicates metabolic acidosis After determining type of acidosis, check bicarb to determine compensation for acidosis and check electrolytes to calculate anion gap Metabolic acidosis can present with tachypnea (Kussmaul breathing) and hypotension due to loss of catecholamine function and suboptimal cardiac function at low pH Treat with IV fluids and address the underlying cause, limited role for bicarb References Burger MK, Schaller DJ. Metabolic Acidosis. [Updated 2020 Nov 20]. In: StatPearls [I...
2021-06-2306 minEmergency Medical MinutePodcast 642: Vasopressors Contributor: Nick Tsipis, MD Educational Pearls: Epinephrine: alpha-1, alpha-2, beta-1, and beta 2 agonist - used in cardiac arrest with positive effects on ROSC in prehospital and peri-hopsital setting Norepinephrine: alpha-1 and beta-1 agonist - used in septic shock to increase cardiac output and peripheral vasoconstriction Phenylephrine: alpha-1 adrenergic agonist - used in spinal/neurogenic shock as well as medication-induced peri-procedural hypotension (propofol for RSI) as it only helps with vasoconstriction Dopamine: alpha-1, alpha-2, beta-1, beta 2, and dopamine agonist - used for sepsis in the past, but not recommended due to dysrhythmias Vasopressin: V1 agonist (va...
2021-02-2208 min
ER-Rx: An ER + ICU PodcastEpisode 43- An expert talks: Awake intubationTune in as Dr. Nick Tsipis from the Emergency Medical Minute takes over the ER-Rx Podcast to discuss awake intubation.Please click HERE to leave a review of the podcast!References:https://litfl.com/awake-intubation/https://emcrit.org/emcrit/awakeintubation/The rest are found on my Read by QxMD collectionDisclaimer: The information contained within the ER-Rx podcast episodes, errxpodcast.com, and the @errxpodcast Instagram page is for informational/ educational purposes only, is not meant to replace professional medical judgement, and does not constitute a provider-patient r...
2021-02-0409 min
Emergency Medical MinutePodcast 614: PerichondritisContributor: Nick Tsipis, MD Educational Pearls: Perichondritis involves infection of not only the connective tissue of the ear but typically the cartilage as well Symptoms include erythema, ear pain, and fevers The most common bacterial cause is Pseudomonas. Perichondritis often occurs after a wound or piercing, but trauma is not necessary for the infection to occur Anti-pseudomonal coverage is essential with typically oral agents for milder disease and IV antibiotics for severe infections Can have devastating outcomes if not treated aggressively and/or treated early due to poor blood supply to the cartilage of the ear
2020-11-1704 min
Emergency Medical MinuteUnfilterED #11: Dr. Ricky DhaliwalDr. Tsipis sits down with colleague Dr. Ricky Dhaliwal for some insightful conversation regarding the differences between academic and community settings as well as the various roles of advocacy in medicine. Time Stamps 00:23 Banter and introductions 2:41 upbringing in 1st generation immigrant Indian household 14:30 losing culture as 2nd gen immigrant 7:32 Balancing family and work with a two doc family 8:32 President of EMRA 10:42 Working in academia vs community 13:29 New job advice 15:55 Nick talks about being the product of your environment and needing to b...
2020-11-1140 min
Emergency Medical MinuteUnfilterED #10: Debi SmithGeneral Counsel attorney, Debi Smith, joins Dr. Nick Tsipis to discuss the ins and outs of healthcare law. Many people forget that a subpoena only compels attendance to a court date, it does not compel one to provide any information on a case without a specific HIPAA compliant authorization for use and disclosure of protected health information. Tune in for more details, perspective on the intricacies of the legal world as it pertains to medicine and for tips on how to navigate different general situations from contracts to litigation. Time Stamps 0:47 Legal Disclaimer...
2020-09-2324 minER-Rx: An ER + ICU PodcastEpisode 17- The Emergency Medical Minute meets ER-RxIn case you missed it, last week Dr. Nick Tsipis from the Emergency Medical Minute discussed a few rapid-fire ER topics with our host, Adis Keric. Check out the full episode here or on the Emergency Medical Minute podcast! *Correction to figures quoted on anticoagulation reversal pricing. High-dose Andexxa regimen maxes out around $60,000 and Kcentra maxes out at $6,000. So there is still a massive price difference, but not as high as quoted in the audio.References: Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. J Res...
2020-08-0419 min
Emergency Medical MinuteRapid Fire Pharmacy Review with Adis Keric of ER-RxMeet Adis Keric, Board Certified Pharmacotherapy Specialist and a Board Certified Critical Care pharmacist who works in the Emergency Department and ICU of level 1 trauma center Regions Hospital in Saint Paul, MN. Adis is the founder and host of a new FOAMed podcast, ER-Rx. He started the podcast to inform clinicians in the ED and ICU about up-to-date, appropriate and optimal use of medications in different clinical scenarios. Dr. Nick Tsipis sits down with Adis to discuss some pearls in Emergency Medicine Pharmacy. Time Stamps: 0:10 Intros 4:35 Antibiotics 8:30 Post-Intubation Sedation
2020-07-2918 min
Emergency Medical MinutePodcast 574: Cyanide ToxicityContributor: Nick Tsipis, MD Educational Pearls: Significant cyanide exposure most commonly occurs from fire/smoke exposure particularly when plastics are involved Cyanide binds to cytochrome oxidase leading to the use of anaerobic metabolism which causes a profound lactic acidosis Classic toxicity includes a rapid loss of consciousness, hypotension, bradycardia, respiratory depression, and seizures Mild exposures can lead to nausea/vomiting, headaches, and other nonspecific symptoms. Sometimes patients will complain of an almond taste. Cyanide toxicity will manifest on labs by a profound anion gap acidosis with elevated lactate (but don't wait for them to ponder the...
2020-06-2305 min
Emergency Medical MinutePodcast 573: Arsenic ToxicityContributor: Nick Tsipis, MD Educational Pearls: Arsenic is a heavy metal that binds to multiple cellular enzymes and inhibits aerobic metabolism It is primarily absorbed through the skin, respiratory and GI tract. The classic symptoms of heavy metal exposure are GI irritation (watery diarrhea, vomiting and abdominal pain) with multisystem organ failure. Neuropathy can present insidiously Initial work up includes EKG, and basic lab work (expect a delayed rise in liver function tests). Acute arsenic ingestions can sometimes show up on imaging as it is radioapaque Diagnosis is usually made with the history and evidence of mult...
2020-06-2204 min
Emergency Medical MinutePodcast 564: Cardiac Ischemia Management UpdateContributor: Nick Tsipis, MD Educational Pearls: Recent randomized controlled trial compared early intervention (PCI/CABG) to medical management for those diagnosed with moderate to severe cardiac ischemia on stress testing Primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest Secondary outcome was death from cardiovascular causes or myocardial infarction. The study reported that patients who had more aggressive invasive procedures early on in treatment had a 2% increase in poor outcomes in the immediate period after intervention (6 months) but long term had a 2...
2020-05-1905 min
Emergency Medical MinutePodcast 562: COVID-19 OcclusionsContributor: Nick Tsipis, MD Educational Pearls: Case series reported 5 cases of generally young and healthy patients with COVID-19 who presented to the ER with acute stroke Now several case series showing cardiovascular involvement or complications related to COVID-19 While these case series may shed light on the nature of COVID-19 complications, it's worth remembering that so far these cases represent a few unique instances and we need more studies and data to pronounce COVID-19 infected patients at higher risk of thromboembolic events like strokes and heart attacks References Oxley, T. et al. Large-Vessel...
2020-05-1202 min
Emergency Medical MinutePodcast 548: Adrenal CrisisContributor: Nick Tsipis, MD Educational Pearls: Congenital adrenal hyperplasia (CAH) is a group of enzyme deficiencies in the adrenals leading to a deficiency of hormones normally synthesized by the adrenals (mineralocorticoids, glucocorticoids, androgens) 21-hydroxylase is most commonly the deficient enzyme. 21-hydroxylase is needed to produce aldosterone and cortisol, and those with chronic cortisol deficiencies need daily steroid replacement Aldosterone, made in the kidney as part of the renin-angiotensin-aldosterone system (RAAS), increases blood pressure via salt and water retention to maintain adequate organ perfusion Adrenal crisis results in a loss of cortisol leading to hypoglycemia and potential...
2020-03-1005 min
Emergency Medical MinutePodcast 543: Scoring Blunt Traumatic Aortic InjuryAuthor: Nick Tsipis, MD Educational Pearls: Aortic injury caused by blunt trauma is very rare Chest x-ray findings might include widening of the mediastinum Ligamentum arteriosum (remnant of the ductus arteriosus) tethers the aorta to the chest wall, potentially causing injury with abrupt decelerations and motion XR lacks significant sensitivity (around 75%) to be utilized in many cases CT angiogram (CTA) of the chest is typically the preferred test but comes with potential risks including radiation exposure NEXUS Decision Instrument (NEXUS DI) is a scoring tool that may provide value in determining the need for additional imaging
2020-02-2403 min
Emergency Medical MinutePodcast 507: Who gonna crump?Contributor: Nick Tsipis, MD Educational Pearls: Communication proves time and time again to be most helpful in preventing surprises after patient admission Frequent re-evaluations and repeat vital signs can be important to evaluating a patient's risk for deterioration once admitted as well as selecting the proper level of care at admission Broad categories of patients who most commonly have a change in condition after admission are septic patients and those admitted for respiratory complaints References Kennedy M, Joyce N, Howell MD, et al. Identifying infected ED patients admitted to the hospital ward at...
2019-10-0705 min
Emergency Medical MinutePodcast #377: EndocarditisAuthor: Nick Tsipis, MD Educational Pearls: Persistent fever or positive blood cultures should raise suspicion for endocarditis Patients with recent dental procedures, recent cardiac surgeries are at risk, or who inject drugs are at higher risk Physical exam findings may include fever with a new murmur, Janeway lesions, Osler nodes, and/or splinter hemorrhages References: Long B, Koyfman A. Infectious endocarditis: An update for emergency clinicians. Am J Emerg Med. 2018 Sep;36(9):1686-1692. doi: 10.1016/j.ajem.2018.06.074. Epub 2018 Jul 2. Review. PubMed PMID: 30001813. Murdoch DR, Corey GR, Hoen B et. al...
2018-09-1003 min