Episode 902: Liver Failure and Cirrhosis
Emergency Medical Minute
Contributor: 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 Spontaneous...
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Episode 901: Underdosing in Status Epilepticus
Emergency Medical Minute
Contributor: 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 1. Cetnarowski A, Cunningham B, Mullen C, Fowler M....
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Episode 900: Ketamine Dosing
Emergency Medical Minute
Contributor: 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 minutes. IM for acute agitation If a patient is out of control and a...
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Episode 899: Thrombolytic Contraindications
Emergency Medical Minute
Contributor: 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...
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Episode 898: Takotsubo Cardiomyopathy
Emergency Medical Minute
Contributor: 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 a...
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Episode 897: Adrenal Crisis
Emergency Medical Minute
Contributor: 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...
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Podcast 896: Cancer-Related Emergencies
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: Cancer-related emergencies can be sorted into a few buckets: Infection Cancer itself and the treatments (chemotherapy/radiation) can be immunosuppressive. Look out for conditions such as sepsis and neutropenic fever. Obstruction Cancer causes a hypercoagulable state. Look out for blood clots which can cause emergencies such as a pulmonary embolism, stroke, superior vena cava (SVC) syndrome, and cardiac tamponade. Metabolic Cancer can affect the metabolic system in a variety of ways. For example, certain cancers like bone...
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Episode 895: Indications for Exogenous Albumin
Emergency Medical Minute
Contributor: 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...
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Episode 894: DKA and HHS
Emergency Medical Minute
Contributor: Ricky Dhaliwal, MD Educational Pearls: What are DKA and HHS? DKA (Diabetic Ketoacidosis) and HHS (Hyperosmolar Hyperglycemic State) are both acute hyperglycemic states. DKA More common in type 1 diabetes. Triggered by decreased circulating insulin. The body needs energy but cannot use glucose because it can’t get it into the cells. This leads to increased metabolism of free fatty acids and the increased production of ketones. The buildup of ketones causes acidosis. The kidneys attempt to compensate for the acidosis by increasing diuresis. These patients...
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Episode 893: Home Treatments for Button Battery Ingestion
Emergency Medical Minute
Contributor: 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...
info_outlineContributor: Meghan Hurley MD
Educational Pearls:
What is a nerve block?
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A nerve block is the medical procedure of injecting anesthetic into the area around a nerve to block pain signals.
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They are typically done with ultrasound guidance.
Are nerve blocks effective?
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Most of the information we have about nerve blocks is extrapolated from fascia iliaca blocks. This nerve block targets the fascia iliaca compartment, which contains the femoral, lateral femoral cutaneous, and obturator nerves. These blocks are commonly done for hip fractures to help stabilize the patient while awaiting surgical repair.
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The data for these types of injections is strong. They decrease pain, they decrease total morphine equivalents needed while a patient is in the hospital, they help mobilize patients earlier and start physical therapy earlier, and they help patients leave the hospital about a day earlier.
What is an example of an agent that can be used?
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Bupivacaine. A long acting amide-type local anesthetic. It works best when paired with epinephrine which causes local vasoconstriction and allows the bupivaciaine to bathe the nerve for longer. It gives 5-15 hours of anesthesia (complete sensation loss), and up to 30 hours of analgesia (pain loss).
What’s an example of another block that can be done?
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An Erector Spinae Plane (ESP) block is performed in the paraspinal fascial plane in the back. This can be used for pain around the ribs and before a variety of medical procedures including a Nuss procedure, thoracotomies, percutaneous nephrolithotomies, ventral hernia repairs, and even lumbar fusions.
What is one potential complication of a nerve block?
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Local Anesthetic Systemic Toxicity (LAST).
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There are three ways this can happen:
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1) Using too much total anesthetic (Maximum dose of bupivacaine is 2.5 mg/kg).
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2) Too much anesthetic is injected into a confined space which then gets absorbed into the venous system.
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3) Injecting directly into the vasculature by mistake.
What are the signs that this complication has occurred?
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Perioral tingling
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Stupor
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Coma
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Seizures
What can that cause?
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Cardiovascular collapse
How is that treated?
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Intralipid AKA Soybean Oil, or “lipid emulsion” should be given as a bolus followed by a drip. These patients need to be admitted.
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Bolus 1.5 ml/kg (lean body mass) intravenously over 1 min (max ~100 ml).
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Continuous infusion at 0.25 mL/kg/min. Max dosing in the first 30 minutes is around 100 ml/kg.
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Fun fact: Patients being treated for LAST with intralipid cannot undergo general anesthesia because the intralipid will impact the anesthesia drugs.
References
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Long B, Chavez S, Gottlieb M, Montrief T, Brady WJ. Local anesthetic systemic toxicity: A narrative review for emergency clinicians. Am J Emerg Med. 2022 Sep;59:42-48. doi: 10.1016/j.ajem.2022.06.017. Epub 2022 Jun 13. PMID: 35777259.
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Carvalho Júnior LH, Temponi EF, Paganini VO, Costa LP, Soares LF, Gonçalves MB. Reducing the length of hospital stay after total knee arthroplasty: influence of femoral and sciatic nerve block. Rev Assoc Med Bras (1992). 2015 Jan-Feb;61(1):40-3. doi: 10.1590/1806-9282.61.01.040. Epub 2015 Jan 1. PMID: 25909207.
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Jain N, Kotulski C, Al-Hilli A, Yeung-Lai-Wah P, Pluta J, Heegeman D. Fascia Iliaca Block in Hip and Femur Fractures to Reduce Opioid Use. J Emerg Med. 2022 Jul;63(1):1-9. doi: 10.1016/j.jemermed.2022.04.018. Epub 2022 Aug 4. PMID: 35933265.
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Kot P, Rodriguez P, Granell M, Cano B, Rovira L, Morales J, Broseta A, Andrés J. The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019 Jun;72(3):209-220. doi: 10.4097/kja.d.19.00012. Epub 2019 Mar 19. PMID: 30886130; PMCID: PMC6547235.
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Lee SH, Sohn JT. Mechanisms underlying lipid emulsion resuscitation for drug toxicity: a narrative review. Korean J Anesthesiol. 2023 Jun;76(3):171-182. doi: 10.4097/kja.23031. Epub 2023 Jan 26. PMID: 36704816; PMCID: PMC10244607.
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Weinberg, Guy. LipidRescue™ Resuscitation. http://www.lipidrescue.org/
Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII