Laboring Under Pressure Episode 3: Hypertensive Disorders of Pregnancy with Dr. Kiersten Williams
Emergency Medical Minute
Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS3 Show Pearls Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide. Hypertension (HTN) complicates 2-8% of pregnancies The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart There is a range of HTN disorders Chronic HTN which could have superimposed preeclampsia (preE) on top Gestational HTN in which there are no lab abnormalities PreE w/o severe features Protein in urine Urine protein >300 mg in 24 hours Urine...
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Episode 920: Pediatric Growth Estimates
Emergency Medical Minute
Contributor: Sean Fox, MD Educational Pearls: Newborns may lose up to 10% of their birth weight in the first week of life Weight loss is greatest in exclusively breastfed infants Should regain birth weight by age 2 weeks Newborns should gain an average of 30g (1 oz) per day in the first 3 months of life Some will gain more and some will gain less Infants double their birth weight by 6 months of life and triple their weight by 12 months A 1-year-old should weigh on average 10 kg (22 lbs) A 3-year-old should weigh on average 15 kg (33 lbs) 2-year-olds are between 10-15 kg...
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Episode 919: EKG Criteria for Adenosine
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: SVT: supraventricular tachycardia Pharmacotherapy for SVT includes drugs that block the AV node, such as adenosine EKG criteria before adenosine administration in SVT Regular rhythm Monomorphic: all QRS complexes are identical If the EKG is polymorphic, with QRS complexes displaying changing morphologies, it is unsafe to administer adenosine Adenosine can worsen polymorphic VTach and lead to VFib References Ganz, Leonard I., and Peter L. Friedman. “Supraventricular Tachycardia.” New England Journal of...
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Episode 918: Automated Blood Pressure Cuffs
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: How does an automated blood pressure cuff work? Automated blood pressure cuffs work differently than taking a manual blood pressure. While taking a manual blood pressure, one typically listens for Korotkoff sounds (turbulent flow) while slowly deflating the cuff. An automatic blood pressure cuff only senses the pressure in the cuff itself and specifically pays attention to oscillations in the pressure caused by when the pressure of the cuff is between the systolic (heart squeezing) and diastolic (heart relaxed) pressures. These...
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Episode 917: Heat-Related Illnesses
Emergency Medical Minute
Contributor: Megan Hurley, MD Educational Pearls: Heat cramps Occur due to electrolyte disturbances Most common electrolyte abnormalities are hyponatremia and hypokalemia Heat edema Caused by vasodilation with pooling of interstitial fluid in the extremities Heat rash (miliaria) Common in newborns and elderly Due to accumulation of sweat beneath eccrine ducts Heat syncope Lightheadedness, hypotension, and/or syncope in patients with peripheral vasodilation due to heat exposure Treatment is removal from the heat source and rehydration (IV fluids or Gatorade) ...
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Episode 916: Central Cord Syndrome
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is Central Cord Syndrome (CCS)? Incomplete spinal cord injury caused by trauma that compresses the center of the cord More common in hyperextension injuries like falling and hitting the chin Usually happens only in individuals with preexisting neck and spinal cord conditions like cervical spondylosis (age-related wear and tear of the cervical spine) Anatomy of spinal cord Motor tracts The signals the brain sends for the muscles to move travel in the corticospinal tracts of the spinal cord The tracts that control the...
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Episode 915: Severe Burn Injuries
Emergency Medical Minute
Contributor: Megan Hurley, MD Educational Pearls: Initial assessment of patients with severe burn injuries begins with ABCs Airway: consider inhalation injury Breathing: circumferential burns of the trunk region can reduce respiratory muscle movement Circulation: circumferential burns compromise circulation Exposure: Important to assess the affected surface area Escharotomy: emergency procedure to release the tourniquet-ing effects of the eschar Differs from a fasciotomy in that it does not breach the deep fascial layer PEEP = positive end-expiratory pressure ...
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Podcast 914: Neuroleptic Malignant Syndrome (NMS)
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is NMS? Neuroleptic Malignant Syndrome Caused by anti-dopamine medication or rapid withdrawal of pro-dopamenergic medications Mechanism is poorly understood Life threatening What medications can cause it? Typical antipsychotics Haloperidol, chlorpromazine, prochlorperazine, fluphenazine, trifluoperazine Atypical antipsychotics Less risk Risperidone, clozapine, quetiapine, olanzapine, aripiprazole, ziprasidone Anti-emetic agents with anti dopamine activity Metoclopramide, promethazine, haloperidol Not...
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Episode 913: Vasopressors after ROSC
Emergency Medical Minute
Contributor: Travis Barlock MD Educational Pearls: Recent study assessed outcomes after ROSC with epinephrine vs. norepinephrine Observational multicenter study from 2011-2018 285 patients received epineprhine and 481 received norepinephrine Epinephrine was associated with an increase in all-cause mortality (primary outcome) Odds ratio 2.6; 95%CI 1.4-4.7; P = 0.002 Higher cardiovascular mortality (secondary outcome) Higher proportion of unfavorable neurological outcome (secondary outcome) Norepinephrine is the vasopressor of choice in post-cardiac arrest care References ...
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Podcast 912: Narcan (Naloxone)
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: Opioid Epidemic- quick facts Drug overdoses, primarily driven by opioids, have become the leading cause of accidental death in the U.S. for individuals aged 18-45. In 2021, opioids were involved in nearly 75% of all drug overdose deaths The rise of synthetic opioids like fentanyl, which is much more potent than heroin or prescription opioids, has played a major role in the increase in overdose deaths What is Narcan AKA Naloxone? Competitive opioid antagonist. It sits on the receptor but doesn’t activate it. When do we give Narcan?...
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