Episode 854: Tranq (xylazine) with Heroin
Emergency Medical Minute
Contributor: 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 It is not an opioid,...
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Podcast 853: Critical Care Medications - Vasopressors
Emergency Medical Minute
Contributor: 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...
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Podcast 852: Angioedema After Thrombolysis
Emergency Medical Minute
Contributor: 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 surface...
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Podcast 851: High-Dose Nitroglycerin in SCAPE
Emergency Medical Minute
Contributor: 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...
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Podcast 850: Cardiac Arrest - Entertainment vs. Reality
Emergency Medical Minute
Contributor: 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...
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Mental Health Monthly #15: Psychosis in the ED: Part I
Emergency Medical Minute
Contributors: 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...
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Podcast 849: Large Vessel Occlusions
Emergency Medical Minute
Contributor: 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? Distal ICA, M1 or M2 segments of the MCA, A1 or A2 segments of the ACA, and some evidence for...
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Podcast 848: Non-Traditional RSI
Emergency Medical Minute
Contributor: 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...
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Podcast 847: ECMO CPR
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Extracorporeal Membrane Oxygenation (ECMO) has been attempted as an adjunct to CPR during cardiac arrest but few studies on outcomes exist One prior small study stopped early when it showed ECMO with CPR (ECPR) was significantly superior to CPR Recent large, multicenter randomized control study in Netherlands evaluated neurologic outcomes in CPR versus ECPR At 30 days and 6 months no significant difference between the groups was found More studies are required determine if certain patients may benefit from ECPR References...
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Podcast 846: Early Repolarization vs. Anterior STEMI
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: Early repolarization a benign EKG pattern that can mimic an anterior STEMI Can be seen in the anterior leads typically in young male patients Can differentiate Early Repolarization vs Anterior STEMI by looking at four variables: Corrected QT interval QRS amplitude in V2 R wave amplitude in V4 ST elevation 60 ms after J point in V3 These four variables can be plugged into a formula (available on MDCalc) Note that a longer QT is more corelated with STEMI References Macfarlane PW, Antzelevitch C, Haissaguerre M, et al. The Early...
info_outlineContributor: 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
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- 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
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- Primary complication is with radial nerve, look for wrist drop!
- May require reduction and splinting
- Distal humerus fractures can include supracondylar fractures and involve the radius or ulna
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- One atypical is the Holstein-Lewis fracture, that can cause radial nerve damage
- Management is varied depending on the exact type of distal humerus fracture
- Assess degree of angulation, neurovascular status, and likelihood of compartment syndrome both before and after splint application
References
Attum B, Thompson JH. Humerus Fractures Overview. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482281/
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