Tox Talks 2025 Recap 2, Methemoglobinemia and Errors
Emergency Medical Minute
Contributors: Travis Barlock MD, Ian Gillman PA, Jacob Altholz MD, Jeffrey Olson MS4 In this episode, EM attending Travis Barlock and medical student Jeffrey Olson listen in to the two remaining cases presented from EMM’s recent event, Tox Talk 2025. Talk 1- Methemoglobinemia- Ian Gillman Cyanosis + chocolate-colored blood + normal PaO₂ + pulse ox stuck at ~85% = Methemoglobinemia → Treat with methylene blue The medications that can cause it can be remembered with… Watch out with methylene blue as it can cause serotonin syndrome While treating with methylene blue the...
info_outline
Podcast 992: Fentanyl for Asthma
Emergency Medical Minute
Contributor: Alec Coston, MD Educational Pearls: BiPAP is often effective in severe asthma, but many patients struggle with mask tolerance due to intense air hunger–driven anxiety, often compounded by hypoxia. Benzodiazepines are commonly used for anxiety, but they can depress respiratory drive, making clinical improvement difficult to interpret (a lower RR may reflect sedation rather than true physiologic improvement). Low-dose fentanyl is a useful alternative when patients cannot tolerate BiPAP despite coaching. Opioids blunt the perception of dyspnea and are well established for...
info_outline
Episode 991: BRASH
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls BRASH Syndrome: Bradycardia Renal Failure AV Nodal Blockade Shock Hyperkalemia Clinical Features: Profound bradycardia and shock in patients on AV nodal blockers: Commonly, Beta Blockers or Calcium Channel Blockers Etiology: Caused by an inciting kidney injury: Common triggers include precipitating illness, dehydration, or medications Results in hyperkalemia The enhanced effect of the combination of AV nodal blockade and hyperkalemia leads to a more profound presentation of shock. ...
info_outline
Episode 990: Tramadol, or rather, Trama-don’t
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is tramadol and how does it work? Tramadol is a Schedule IV opioid analgesic used for moderate pain and is often perceived as safer than other opioids due to lower abuse potential. It is a prodrug with weak direct μ-opioid receptor activity. The parent compound also inhibits serotonin and norepinephrine reuptake, giving it SSRI/SNRI-like properties. Tramadol is metabolized by CYP2D6 into O-desmethyltramadol (ODT), which has significantly stronger μ-opioid receptor agonism than the parent drug. What are the concerns with...
info_outline
Episode 989: Young Strokes
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: The Case 24F brought in for anxiety. Patient is tearful, not talking, and potentially hyperventilating. History from boyfriend is that she suddenly stopped talking and started crying and it was hard to understand what she was saying. On exam, patient appears anxious and has a gaze preference for the right side and is still having difficulty speaking. Decision is made to stroke alert patient. CT shows early MCA stroke and M2 occlusion. Patient is treated by IR with mechanical thrombectomy. What are the risk factors for strokes in young...
info_outline
Episode 988: Infant Botulism
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: A 2025 multistate outbreak of infant botulism has been linked to ByHeart infant formula As of December 10-17th, there have been at least 51 infants with suspected or confirmed botulism who were exposed to this formula across 19 states All reported cases resulted in hospitalization but no deaths reported to date Infant botulism Occurs when C. botulinum spores germinate in the infant’s intestine, producing toxin Spores are classically found in honey but can also be in dirt or contaminated in infant formula Infants are...
info_outline
Carepoint Journal Club: Trauma Discussion
Emergency Medical Minute
Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.
info_outline
Episode 987: Cough Suppressants
Emergency Medical Minute
Contributor: Meghan Hurley, MD Educational Pearls: OTC Medications Dextromethorphan (DM) Most common OTC cough suppressant Minimal efficacy: Little evidence that it shortens the duration or severity of cough. Potential side effects: At recommended doses: Mild dizziness, drowsiness, GI symptoms Higher doses: Decreased consciousness, dissociative effects Guaifenesin Found in Mucinex and other severe cough/cold products Thins secretions and loosens mucus in airways No more effective than increasing oral fluid intake Prescription Medications Codeine-containing products ...
info_outline
Episode 986: Lateral Canthotomy in Emergency Settings
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is orbital compartment syndrome, and how is it assessed in the emergency room? Orbital compartment syndrome (OCS) is an emergent ophthalmic condition in which intraorbital pressure in the orbital compartment rises dramatically, compromising perfusion of the optic nerve and retina, leading to risk of irreversible vision loss. OCS occurs in the context of traumatic lesions with retrobulbar hemorrhage. Intraocular pressures (IOP) are measured via tonometry as a surrogate for intraorbital pressures, with emergent pathology being present when...
info_outline
Episode 985: Amiodarone vs. Lidocaine
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: How do amiodarone and lidocaine work on the heart? Amiodarone Blocks potassium channels (Class III effect). Also blocks sodium and calcium channels. Additional noncompetitive beta-blocker effects. Stabilizes cardiac tissue, slows heart rate, and suppresses both atrial and ventricular arrhythmias. Lidocaine Blocks fast sodium channels in ventricular tissue (Class Ib). Shortens the action potential in ventricular myocardium, especially in ischemic tissue. Suppresses abnormal automaticity in damaged/irritable myocardium. Which one should...
info_outlineContributor: Michael Hunt, MD
Educational Pearls:
- Cirrhosis is the end stage of chronic structural damage to the liver. This is most commonly due to alcohol but other causes viral hepatitis and hepatotoxic drugs
- Cirrhotic patients are very prone to GI bleeding and infections, partially due to the role the liver plays in producing immune and clotting factors
- These patients can easily become “sick”. Use the shock index (heart rate / systolic blood pressure) as a rapid assessment of hemodynamic status. >0.7 is worrisome, >1 should prompt resuscitation.
- Because cirrhotic patients are immunocompromised, do not rely on the presence of fever and peritonitis to diagnose spontaneous bacterial peritonitis (SBP), and have a low threshold to perform a diagnostic paracentesis
- Polymorphonuclear (PMN) count > 250 in the ascitic fluid suggests SBP
- With GI bleeding in cirrhotics, antibiotics have a mortality benefit, while PPIs and octreotide have limited benefit
References
Chinnock B, Hendey GW, Minnigan H, Butler J, Afarian H. Clinical impression and ascites appearance do not rule out bacterial peritonitis. J Emerg Med. 2013 May;44(5):903-9. doi: 10.1016/j.jemermed.2012.07.086. Epub 2013 Mar 7.
Pericleous M, Sarnowski A, Moore A, Fijten R, Zaman M. The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: a review of current guidelines and recommendations. Eur J Gastroenterol Hepatol. 2016 Mar;28(3):e10-8. doi: 10.1097/MEG.0000000000000548.
Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, Soares-Weiser K, Mendez-Sanchez N, Gluud C, Uribe M.Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding - an updated Cochrane review. Aliment Pharmacol Ther. 2011 Sep;34(5):509-18. doi: 10.1111/j.1365-2036.2011.04746.x. Epub 2011 Jun 27.
Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD