Episode 963: Antihypertensives and Emergency Room Considerations
Emergency Medical Minute
Contributor: Alec Coston, MD Educational Pearls: For patients presenting to the emergency room with hypertension, clinicians should determine if it is isolated and uncomplicated, or involves comorbidities with more complex underlying pathophysiology. For uncomplicated and isolated hypertension, first-line treatment is thiazide diuretics. How do thiazide diuretics work to treat hypertension? Thiazide diuretics work by blocking sodium and chloride resorption in the kidneys. “Where sodium goes, water follows,” thus promoting diuresis and lowering blood pressure. Examples...
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Episode 962: HEART Score
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: How do we risk-stratify chest-pain patients? One option is the HEART score This score predicts a patient’s 6-week risk of a major adverse cardiac event. Ex. Cath procedure, CABG, PCI, death H stands for History Ask 1) Was the patient diaphoretic? 2) Did they have nausea and/or vomiting? 3) Did the pain radiate down the right or left arm? 4) Was it exertional? Yes to one = one point. Two or more = two points. E stands for EKG One point for left ventricular hypertrophy, t-wave inversions, new bundle-branch blocks. No points for first...
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Episode 961: Cell Phone Sign
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: A prospective study at the Mayo Clinic Rochester was conducted to examine whether patients actively using their phones on initial assessment in the ED was associated with higher discharge rates The study included 292 patients, and only about 15% of patients were on their phone The patients on their phone tended to be a younger demographic Scribes were trained to record the data during their shifts The results did show that patients on their phone have a higher rate of discharge 94% chance of discharge if the patient is on their phone 64%...
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Episode 960: Frank's Sign - A Marker for Coronary Artery Disease
Emergency Medical Minute
Contributor: Travis Barlock MD Educational Pearls Frank’s sign is a curious physical exam finding first described in the literature in 1973 Bilateral earlobe creases are recognized as a marker of coronary artery disease and cerebrovascular disease Some studies have found an increase in all-cause mortality in patients with bilateral diagonal earlobe creases The pathophysiology is still not fully understood One 2020 study found histopathological changes associated with diagonal earlobe creases, potentially linking them via a model of hypoxia/reoxygenation References Elliott WJ,...
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Episode 959: The KLM Flight Disaster and Lessons in Healthcare Communication
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: The KLM Flight Disaster, also known as the Tenerife Airport Disaster, occurred on 27 March 1977. It involved the collision of two Boeing 747 passenger jets from KLM and Pan Am Airlines, resulting in 583 fatalities. What fell through the cracks to cause this incident? The captain of the KLM flight believed he had received clearance from air traffic control to take off, when in fact he had not. This captain was one of the most senior pilots in the organization, and the culture often saw senior pilots as infallible and not to be questioned....
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Episode 958: Intranasal Fentanyl
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: How do we take care of kids in severe pain? There are many non-pharmacologic options for pain (i.e. ice, elevation) as well as more conventional medication options (i.e. acetaminophen, NSAIDS) but in severe pain stronger medications might be indicated. These stronger medications include options such as IV morphine, a subdissociative dose of ketamine, as well as intranasal fentanyl. Intranasal fentanyl has many advantages: Studies have shown it might be more effective early on in controlling pain, as in the first 15-20 minutes after...
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Episode 957: Cardiac Asthma
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: Wheezing is classically heard in asthma and COPD, but it can be the result of a wide range of processes that cause airflow limitation Narrowed bronchioles lead to turbulent airflow → creates the wheezing Crackles (rales) suggest pulmonary edema which is often due to heart failure Approximately 35% of heart failure patients have bronchial edema, which can also produce wheezing COPD and heart failure can coexist in a patient, and both of these diseases can cause wheezing It’s vital to differentiate whether the wheezing is due to the...
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Episode 956: Psychedelics and Risk of Schizophrenia
Emergency Medical Minute
Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Psychedelics are being studied for their therapeutic effects in mental illnesses, including major depressive disorder, post-traumatic stress disorder, anxiety, and many others Classic psychedelics include compounds like psilocybin, LSD, and ayahuasca MDMA and ketamine are often included in psychedelic research, but have a different mechanism of action than the others Their mechanism of action involves agonism of the 5HT2A receptor, among others Given their resurgence, there is an increase in recreational use of these substances ...
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Episode 955: Cardiac Effects of COVID-19
Emergency Medical Minute
Contributor: Ricky Dhaliwal, MD Educational Pearls: What factors are considered in a COVID-19 infection? The viral load: Understood as the impact of SARS-CoV-2 viral particles infecting host cell tissue itself (utilizing ACE-2 receptors). Pro-Inflammatory Response: Post-infection, the body's downstream systemic cytokine release (can be both normal or hyperactive, aka “cytokine storm”). What cardiac impacts have been observed with COVID-19? Arrhythmias: The mechanism of COVID-19 infection and arrhythmias is believed to be multifactorial. However, evidence suggests T-cell-mediated...
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Episode 954: Combo Rescue Inhalers - New Guidelines
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: What is a Rescue Inhaler? A rescue inhaler is a medication for people with asthma to quickly reverse the symptoms of an asthma attack. Historically albuterol (Short Acting Beta Agonist (SABA)) monotherapy has been the mainstay rescue inhaler. This is because albuterol works fast and is relatively cheap. \n\n What are Combination Rescue Inhalers? Combination rescue inhalers contain a fast-acting bronchodilator as well as an inhaled corticosteroid (ICS) The steroid helps to reduce some of the chronic airway inflammation that is...
info_outlineContributor: Meghan Hurley MD
Educational Pearls:
What is ATLS?
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Advanced Trauma Life Support (ATLS) is a systematic and comprehensive approach to the evaluation and management of trauma patients
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It was developed by the American College of Surgeons (ACS)
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The key components include the Primary Survey ("ABCDE"), the Secondary Survey, Definitive Care, and Special Considerations
What are the issues with ATLS?
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ATLS relies on many algorithms and rules-of-thumb, which might be helpful for individuals with basic skills and training but might actually present obstacles for those with higher levels of training. Dr. Hurley cites several examples.
Example 1: ABC approach to trauma patients
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ABC stands for Airway, Breathing, and Circulation but focusing on the airway first is not always the best decision.
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Immediate attention may need to be applied to massive hemorrhage.
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Intubating a patient that is hemodynamically unstable may cause cardiac arrest.
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A more helpful phrase might be “Resuscitate before you intubate.”
Example 2: C-spine precautions
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Cervical collars may impede the likelihood of first-pass success when intubating. The risk of complications from a failed airway may often outweigh the risk of causing a spinal cord injury.
Example 3:Cutting clothes off.
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The E of ABCDE stands for exposure which means fully undressing the patient to look for missing injuries. This often involves cutting their clothes off.
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This practice might be too broadly applied and leave low-risk trauma patients without any clothes to wear when discharged home.
Example 4: Digital rectal exam
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A rectal exam can be a useful tool in the evaluation of patients with abdominal or pelvic injuries. It can help screen for rectal bleeding, pelvic fractures, and neurological function
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However, the rectal exam is not a sensitive test. A retrospective study from the Indian Journal of Surgery found that a rectal exam missed 100% of urethra injuries, 92% of spinal cord injuries, 93% of small bowel injuries, 100% of colon injuries, and 67% of rectal injuries in trauma patients.
Example 6: Pushing on pelvis for pelvic injuries
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Pushing on the pelvis to check for instability can cause further damage to an unstable pelvis. Imaging the pelvis is far more important than pressing on it if a pelvic fracture is suspected.
Example 7: FAST exam
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A FAST exam, which stands for "Focused Assessment with Sonography for Trauma," is a rapid ultrasound examination used to assess trauma patients for signs of internal bleeding or organ damage in the abdomen and chest.
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These can be very useful as an initial test to tell a trauma surgeon where to start looking for internal bleeding in an unstable blunt traumatic injury
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If a patient is stable and likely going to get a CT scan whether the FAST is positive or negative then the test is unnecessary
References
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ATLS Subcommittee; American College of Surgeons’ Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013 May;74(5):1363-6. doi: 10.1097/TA.0b013e31828b82f5. PMID: 23609291.
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Bloom BA, Gibbons RC. Focused Assessment With Sonography for Trauma. 2023 Jul 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261902.
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Brown R. Oxygenate and Resuscitate Before You Intubate. Common pitfalls to avoid when managing the crashing airway. EMS World. 2016 Jan;45(1):48-50, 52, 54-5. PMID: 26852546.
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Chrimes N, Marshall SD. Attempt XYZ: airway management at the opposite end of the alphabet. Anaesthesia. 2018 Dec;73(12):1464-1468. doi: 10.1111/anae.14361. Epub 2018 Jul 11. PMID: 29998563.
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Docimo S Jr, Diggs L, Crankshaw L, Lee Y, Vinces F. No Evidence Supporting the Routine Use of Digital Rectal Examinations in Trauma Patients. Indian J Surg. 2015 Aug;77(4):265-9. doi: 10.1007/s12262-015-1283-y. Epub 2015 May 19. PMID: 26702232; PMCID: PMC4688269.
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Groeneveld A, McKenzie ML, Williams D. Logrolling: establishing consistent practice. Orthop Nurs. 2001 Mar-Apr;20(2):45-9. doi: 10.1097/00006416-200103000-00011. PMID: 12024634.
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Morgenstern, J. The FAST exam: overused and overrated?, First10EM, August 30, 2021.
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Rodrigues IFDC. To log-roll or not to log-roll - That is the question! A review of the use of the log-roll for patients with pelvic fractures. Int J Orthop Trauma Nurs. 2017 Nov;27:36-40. doi: 10.1016/j.ijotn.2017.05.001. Epub 2017 May 10. PMID: 28797555.
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Sapsford W. Should the 'C' in 'ABCDE' be altered to reflect the trend towards hypotensive resuscitation? Scand J Surg. 2008;97(1):4-11; discussion 12-3. doi: 10.1177/145749690809700102. PMID: 18450202.
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Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma. 2014 Mar 15;31(6):531-40. doi: 10.1089/neu.2013.3094. Epub 2013 Nov 6. PMID: 23962031; PMCID: PMC3949434.
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII