Episode 972: Hepatic Encephalopathy
Emergency Medical Minute
Contributor: Alec Coston, MD Educational Pearls: Hepatic encephalopathy (HE) is defined as a disruption in brain function that results from impaired liver function or portosystemic shunting. Manifests as various neurologic and psychiatric symptoms such as confusion, inattention, and cognitive dysfunction Although ammonia levels have historically been recognized as important criteria for HE, the diagnosis is ultimately made clinically. An elevated ammonia level lacks sensitivity and specificity for HE Trends in ammonia levels do not correlate with disease improvement or resolution A 2020...
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Episode 971: Calcium Pretreatment for Diltiazem in AFib with RVR
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is atrial fibrillation with rapid ventricular response (AFib with RVR) and how does it differ from atrial fibrillation (AFib)? AFib is an abnormal heart rhythm in which the heart has disorganized atrial electrical activity. This causes the atria to quiver with only select signals being conducted through the Atrioventricular (AV) Node to reach the ventricles and result in ventricular contraction. Often described as “irregularly irregular”, a patient's EKG will present with no discernible P-waves, and irregular R-R intervals. AFib with...
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Episode 970: Fever Management
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Recorded March 2025 What is the best treatment for a fever? Tylenol? Ibuprofen? Combined? Alternating the two? The journal Pediatrics aimed to answer this question with a meta-analysis of 31 randomized controlled trials including 5,009 febrile children. Results showed that both combined and alternating acetaminophen/ibuprofen regimens were significantly more effective at reducing fever at 4 and 6 hours compared with acetaminophen alone, with numbers needed to treat (NNT) of 3 and 4, respectively. High-dose ibuprofen alone also offered modest...
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Episode 969: Shoulder Reduction
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: There are many techniques for reducing a shoulder dislocation A recent study discussed a new variation of closed reduction technique: wrist-clamping shoulder-lifting The patient is in a sitting position The provider holds the wrist of the injured arm with both hands and slowly rotates the arm to 90 degrees of abduction and 60 degrees of external rotation After this traction, the arm is slowly moved to 45 degrees of abduction and 60 degrees of external rotation The provider then secures the patient’s wrist between the provider’s knees and...
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Episode 968: Heavy Metals
Emergency Medical Minute
Contributor: Megan Hurley MD Educational Pearls: Acute toxicity of heavy metals: Gastrointestinal upset is the most common presentation Chronic toxicity of heavy metals: Symptoms depend on the metal ingested Increased risk of cancer Altered mentation Developmental delays (in children) Kidney failure Four heavy metals that are tested for in a general panel and their sources: Lead Old paint (homes built before 1977) or some older toys Pipes of older homes or those with corrosive agents May obtain testing kits from home improvement stores to test water supply Mercury Previously in...
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Episode 967: Dilutional Hyponatremia
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: Dilutional Hyponatremia: Occurs when there is an excess of free water relative to sodium in the body. Causes a falsely low sodium concentration without a true change in total body sodium. Commonly seen in DKA: Hyperglycemia raises plasma osmolality. Water shifts from the intracellular to extracellular space. This dilutes serum sodium, creating apparent hyponatremia. Corrected sodium calculation: Use tools like MDCALC, or apply this formula: Add 1.6 mEq/L to the measured sodium for every 100 mg/dL increase in glucose above 100. Clinical...
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EMSAC 2024
Emergency Medical Minute
Contributors: Col. (Dr.) Stacy Shackelford Dr. Sean Keenan Paramedic Alan Moreland Dr. Chris Tems Kara Napolitano From military-inspired trauma protocols to behavioral health alternatives and cardiac resuscitation, EMS is evolving fast. Our Medical Minutes from EMSAC highlight the growing need for prehospital providers to think critically, act quickly, and adapt to new approaches in trauma, crisis response, and patient advocacy. Educational Pearls: What was covered & recorded at EMSAC 2024 by EMM? Col. (Dr.) Stacy Shackelford, U.S. Air Force trauma surgeon and Director of the Joint Trauma...
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Episode 966: Acetaminophen Toxicity
Emergency Medical Minute
Contributor: 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...
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Episode 965: Oxygen Administration in Trauma Patients
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Many trauma patients are placed on oxygen via non-rebreather A large, multicenter, controlled trial evaluated the outcomes of oxygen administration in trauma patients Patients were randomized to two groups 1. 8-hour restrictive oxygen strategy: only receiving oxygen when the patient’s saturation dropped below 94% 2. 8-hour liberal oxygen strategy: 12-15 liters of oxygen per minute or fraction of inspired oxygen of 0.6-1.0 The study evaluated rates of death or major respiratory complications at 30 days There was no statistical difference...
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Episode 964: Ketamine & Midazolam for Prehospital Seizure Management
Emergency Medical Minute
Contributor: 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%...
info_outlineContributor: Aaron Lessen, MD
Educational Pearls:
- Tramadol is often thought of as a mild-opiate to use for analgesia, but it is a more complicated drug
- Tramadol needs to be metabolized into an effective drug making it not pharmacologically reliable
- 3-10% of people cannot metabolize tramadol and it does not work
- Some others over-metabolize tramadol and it causes greater effect
- Studies have shown it is not any better as a acetaminophen or ibuprofen for analgesia, it can lower a seizure threshold, and it acts to inhibit serotonin reuptake
- Recent study evaluated all-cause mortality of tramadol compared to codeine and found tramadol had nearly double the all-cause mortality as those prescribed codeine
- Overall tramadol has many risks and should be critically evaluated before prescribing
References
Dhesi M, Maldonado KA, Maani CV. Tramadol. [Updated 2021 May 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537060/
Association of tramadol vs codeine prescription dispensation with mortality and other adverse clinical outcomes Xie J, Strauss VY, Martinez-Laguna D, et al. JAMA. 2021;326(15):1504-1515.
Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD
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