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Podcast 553: Airway Management in the Hypoxic COVID-19 Patient (Recorded 4/3/20)

Emergency Medical Minute

Release Date: 04/06/2020

Podcast 748: Botulism show art Podcast 748: Botulism

Emergency Medical Minute

Contributor: Nick Hatch, MD Educational Pearls: Botulism requires a prompt clinical diagnosis as lab results can take about 5 days to return Whale blubber, honey, home fermented foods, homemade wine (especially the wine made in prison), and improperly stored canned food can all contain the toxin The botulinum toxin is create by a Clostridium botulinum that is prevalent on our food and in the soil, but the toxin is readily degraded with heat and light Blocks release of acetylcholine at the neuromuscular junction preventing release of neurotransmitter and therefore the propagation of an...

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Podcast 747: Food Impaction show art Podcast 747: Food Impaction

Emergency Medical Minute

Contributor: Ricky Dhaliwal, MD Educational Pearls: Esophageal food impaction can be managed in the ED prior to calling GI for endoscopy Coca-cola, glucagon, benzodiazepines, calcium channel blockers, and dissolved nitroglycerin are all options to try For pediatric patients, weighted bougies can be used under sedation to attempt retrieval of the food bolus  Always evaluate airway status, especially if the patient cannot maintain secretions References Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J...

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Podcast 746: Elderly Head Trauma on Anticoagulation show art Podcast 746: Elderly Head Trauma on Anticoagulation

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Biggest study to date examined new protocol for repeat head CT in anticoagulated elderly patients with head trauma and an initial negative head CT 0.5%-6% of patients in this category will get a delayed ICH and this can occur up to a week out from initial injury 18% of the study group had an ICH on initial head CT, but the rest who had negative head CT initially received a repeat head CT at 6 hours 0.9% had a bleed identified on repeat head CT 6 hours after initial imaging, but of this group no one had an intervention for this bleed...

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Podcast 745: Nitrous-Induced B12 Deficiency show art Podcast 745: Nitrous-Induced B12 Deficiency

Emergency Medical Minute

Contributor: Alicia Oberle, MD Educational Pearls: Nitrous oxide (N2O) can cause a vitamin B12 deficiency in patients after regular use N2O is used in procedural sedation but also as a popular recreational drug  N2O binds and inactivate B12 in the body, therefore decreasing usable supply Lack of B12, which is essential for myelinating nerves, can lead to subacute combined degeneration of the spinal cord Presentation may include paresthesias, ataxia, gait changes, or bilateral lower extremity motor weakness B12 can be normal on labs, as the B12 is present but inactivated Treatment is...

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Podcast 744: Glucagon for Beta Blocker Toxicity show art Podcast 744: Glucagon for Beta Blocker Toxicity

Emergency Medical Minute

Educational Pearls: Glucagon can be used to treat hypoglycemia and esophageal foreign body, but it can also be used in beta-blocker toxicity to bypass cardiac beta-blockade The superior option for treating bradycardia due to beta-blocker toxicity is glucagon Glucagon has decreased efficacy in patients with heart failure, so increased doses up to 10 mg might be required in the event of beta-blocker toxicity References Khalid MM, Galuska MA, Hamilton RJ. Beta-Blocker Toxicity. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available...

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Podcast 743: Rust Rings show art Podcast 743: Rust Rings

Emergency Medical Minute

Contributor: Jared Scott, MD Educational Pearls: A rust ring can occur after a metallic foreign body is left in the eye for a prolonged period of time Issues occur when the rust ring is left as it can epithelialize and become a permanent spot in the patient’s vision An eye burr or Alger brush can help to gouge out the rust ring in the emergency setting These tools have a failsafe mechanism to prevent the eye burr from going through layers past the cornea (though this does not work if the foreign body is already through the cornea) Referral to ophthalmology, antibiotic drops, and dilating...

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Podcast 742: Pulse Check During CPR show art Podcast 742: Pulse Check During CPR

Emergency Medical Minute

  Contributor: Aaron Lessen, MD Educational Pearls: Pulse checks are necessary during CPR to check for return of spontaneous circulation (ROSC) Previous studies have shown that assessing ROSC with palpating for pulse are not a very consistent Study compared palpating pulses at carotid/femoral artery versus a newly contrived gold standard for pulse checks The gold standard used was an increase in end tidal CO2 + cardiac activity on ultrasound + perfusing rhythm on ECG Carotid artery palpation was the best location to confirm pulse during pulse check, although femoral artery palpation ...

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Podcast 741: Calcium for Cardiac Arrest show art Podcast 741: Calcium for Cardiac Arrest

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Study of nearly 400 patients evaluating giving calcium during cardiac arrest with the endpoint as return of spontaneous circulation (ROSC) Compared giving 1 amp calcium chloride with each round of epinephrine for the first two rounds of epinephrine versus saline placebo ROSC occurred in 19% of patients in the calcium groups versus 27% in saline placebo group No magic drugs in cardiac arrest, good CPR and early defibrillation are still the most important factors for ROSC in cardiac arrest  References Vallentin MF, Granfeldt A, Meilandt C,...

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Podcast 740: Placenta Previa show art Podcast 740: Placenta Previa

Emergency Medical Minute

Contributor: Peter Bakes, MD Educational Pearls: High concern causes of third trimester vaginal bleeding include placenta previa, placental abruption, or vasa previa In placenta previa, the placenta implants over the cervix and this condition Often noted during routine prenatal care on transabdominal ultrasound Patients present with painful vaginal bleeding, usually in the absence of trauma Avoid pelvic exam, transvaginal ultrasound, or digital vaginal exam in placenta previa Risk factors for placenta previa include multiple gestations, previous medical abortions, advanced maternal age,...

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Podcast 739: Perceptions of Dress show art Podcast 739: Perceptions of Dress

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Study examined patient perceptions of providers wearing traditional white coats,  fleece coats and soft-shell jackets Found that white coats were seen as more professional than other types of dress Also found that female physicians were viewed as less professional than their male counterparts regardless of dress Older respondents thought more of white coats than younger respondents Patient perspective should be considered and reiterating roles may help build relationships with patients References Xun H, Chen J, Sun AH, Jenny HE, Liang F,...

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Contributor: Dylan Luyten, MD

Educational pearls:

  • Clinical management of COVID-19 is rapidly evolving, relying on case reports and clinical experience
  • In just a month, the consensus around management of COVID patients with severe hypoxia has shifted from an early intubation strategy to other, non-invasive means
  • Intubating early can quickly consume ventilator resources, require increased intensive care monitoring, and likely leads to longer hospital stays and once COVID patients are intubated, extubation can take days to weeks.
  • In Italy, ventilator supplies were depleted leading to the use of helmet CPAP machines, which appeared to be effective in management of respiratory distress in COVID, though not available for use in the US
  • Non-invasive ventilation such as CPAP/BiPAP is thought to increase risk to staff for infection via aerosolization, and has often been avoided in COVID patients
  • High flow nasal cannulas appear to pose less of a risk of aerosolization of viral particles (especially when a surgical mask is placed over the patient’s nose, mouth and apparatus)
  • Anecdotal evidence from NYC has shown success allowing conscious patients to maintain hypoxia on HFN, where they will self prone to help with lung recruitment, and seemingly do well despite persistent saturations in the 80s or less
  • Hospitals around the country are moving away from the intubate early methodology in favor of high flow oxygen therapy as long as they are not having issues with work of breathing or other complications
  • The pathophysiology of respiratory distress and hypoxia in COVID patients is evolving as well, and some presentations appear similar to disease processes such as high altitude pulmonary edema (HAPE) rather than acute respiratory distress syndrome (ARDS), in that patients are quite well appearing despite phenomenally low oximetry readings. 
    • These select patients appear to be excellent candidates for non-invasive means rather than an early intubation strategy

 

Editor’s note: do not take lightly that intubation is one of the highest risk aerosolization generating procedures, along with many peri-intubation procedures like suctioning, BVM, etc.

 

References

[1]. Sorbello, M. et al. The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice. Anaesthesia. 2020 Mar 27.

[2]. Giwa, AL. Desai A. Duca A. Novel 2019 coronavirus SARS-CoV-2 (COVID-19): An updated overview for emergency clinicians. Emerg Med Pract. 2020 May 1;22(5):1-28. 

[3]. Ather B, Edemekong PF. Airborne Precautions. [Updated 2020 Feb 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD 

Photo Credit: New England Journal of Medicine

https://www.nejm.org/doi/full/10.1056/NEJMc2007589?query=RP